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Home My WebLink AboutBLDP&G-20-005890 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK lQ �-4 CITY YARMOUTH MA DATE[5/15/2020 PERMIT#4--P JOBSITE ADDRESS 110 WHITE ROCK ROAD-YARMOUTHPORT OWNER'S NAME WENDI BRAUN pSAME, . . _ r „..1OWNER ADDRESS _w__ TEL�781-254-2678 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL _ I EDUCATIONAL (Vy RESIDENTIAL'✓-•- PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES® NO FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1111111111111111111 SIM MR NM 1111111 .--- _ 11111.1111111111 MI 11111111111.1 MI Mil CROSS CONNECTION DEVICE .11M IMO Mini INN Win NMI IIIIMIIINIIIMIIIIIIMIIIIIIIIMIMIIIIIIMIMIIN DEDICATED SPECIAL WASTE SYSTEM ( DEDICATED • . iF DEDICATED GRAY WATER SYSTEM * — C I 1- r--- r - • - - p __.. DISHWASHER , 111.1111111111 DRINKING FOUNTAIN FOOD DISPOSER KITCHEN SINK .. FLOOR/AREA DRAIN , _ MINI LAVATORY =ME MO 11.11111111M. SHOWER SERVICE/MOP SINK TOILET URINAL ... ®IIIIMIIIIIIIIIIIMMIII® N1111111111 WASHING MACHINE CONNECTION IIIIMIIIIIIIWI IIIIIIIIIIIIII MINI Mil WATER HEATER ALL TYPES WATER PIPING OTHER WORK ORDER 525250 ,E I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES v NO Li IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Li i OTHER TYPE OF INDEMNITY G BOND LI OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT „ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true r e to the b t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co li wit II ertine provisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `/ PLUMBER'S NAME!STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP JP[ CORPORATION El 3281C PARTNERSHIP[]# mm— 'LLCF# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE L MA ZIP P2664 TEL 508-394-7778 FAX 508-394-8256 I CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM /__-/` (4 The Commonwealth of Massachusetts Department of Industrial Accidents _ ►_(ip, Office of Investigations : ==SIB j Lafayette City Center .= 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E.F. WINSLOW PLUMBING & HEATING CO, INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer? Check the appropriate box: Business Type(required): 1.0 I am a employer with_90 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. #1909A Expiration Date: 01/01/2021 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under § 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' e the/Ihi�ns�and penalties of perjury that the information provided above is true and correct. Signature: ?' � Date: 01/02/2020 Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1.1=IBoard of Health 2.0 Building Department 3.1=ICity/Town Clerk 4.0Licensing Board 5.1=I Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK oTti CITY YARMOUTH MA DATE15/15/20v PERMIT# /?W)I—== —c- 0 JOBSITE ADDRESS 110 WHITEROCK ROAD-YARMOUTHPORT OWNER'S NAME WENDI BRAUN OWNER ADDRESS SAME TEL 781-254-2678 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL J PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:L' PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER • BOOSTER CONVERSION BURNER COOK STOVE • DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER X OTHER__._ -WORK ORDER 525250 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L . NO $ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat to the b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Y PLUMBER-GASFITTER NAME I STEPHEN WINSLOW I LICENSE# 12298 SIGNATURE MP / MGF JP JGF LPGI CORPORATION #C 3281 C PARTNERSHIP # LLC # COMPANY NAME:E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIPI 02664 TEL`508 394 7778 FAX[508-394-8256 CELLI N/A 'EMAIL INSPECTIONS@EFWINSLOW COM The Commonwealth of Massachusetts Department of Industrial Accidents "1=_ ►— Office of Investigations 1=1'� Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 "M www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E.F. WINSLOW PLUMBING & HEATING CO, INC. Address: 8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone #: 508-394-7778 Are you an employer?Check the appropriate box: Business Type(required): 1.❑■ I am a employer with 90 _employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ONon-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. #1909A Expiration Date:01/01/2021 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under § 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' e the and penalties of perjury that the information provided above is true and correct. Signature: l' --- 4- -- Date: 01/02/2020 Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 1.0Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.El Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia