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Home My WebLink AboutBLDP&G-20-005390 -1- I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '6 Ma la' ,luty J CITY SOUTH YARMOUTH MA DATE rd ,� PERMIT# I --PIP'g4'Cet5 V° JOBSITE ADDRESS 80 WILFIN ROAD OWNER'S NAME FRANK WATSON OWNER ADDRESS SAME �.._.. TEL 774-487-0124 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[1 EDUCATIONAL Li RESIDENTIAL Ei PRINT CLEARLY NEW:Li RENOVATION:[ 1 REPLACEMENT: PLANS SUBMITTED: YES Li NOD FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE € _ DEDICATED SPECIAL WASTE SYSTEM ,Ilial, , , iii DEDICATED GAS/OIL/SAND SYSTEM � � DEDICATED GREASE SYSTEM Malllin.aistillitilitaltilill DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM onW .NMI I i i MI a DISHWASHER DRINKING FOUNTAIN f 1 nn FOOD DISPOSER FLOOR/AREA DRAIN Mott'Mali Mail Mil Milititini mi Om no sillall INTERCEPTOR(INTERIOR) KITCHEN SINK r � LAVATORY I __..,._.. __ , i C 5 ROOF DRAIN [ E ii SHOWER STALL SERVICE/MOP SINK 1 1 .. TOILET it URINAL E 1 ..w WASHING MACHINE CONNECTION e ' Ma, .1.1 WATER HEATER ALL TYPES I F MN WATER PIPING Ns intattitittitt IM mu Mint iiiiiit liiiiiiiiiiii OTHER .. . . �x. inmallan 40 �j um ow in�� !Elia WO 5236 INSURANCE COVERAGE: I have a current liability insurance policyor its substantial equivalent which meets the requirements of MGL Ch.142. YES ..'... NO [... q q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Li j OTHER TYPE OF INDEMNITY E BOND PI 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 [11 AGENT [.:l, 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 with II ertine proyisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / _ 10 "+ i"..a`I.r PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 ] SIGNATURE MP[1:;_] JP-1 CORPORATIOND# 3281C PARTNERSHIP # LLC # mm COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 1 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents i =- ► Office of Investigations = �= 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.❑■ 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. Ill 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.111 Other i *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 the ins and penalties of perjury that the information provided above is true and correct. Signature: Y "` .....1.--- 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=1Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • i% 11"�ui=i1® t CITY SOUTH YARMOUTH 1, MA DATE Ar, ,[ 4 , `,PERMIT# , r _V 0"5` ° JOBSITE ADDRESS 80 WILFIN ROAD OWNER'S NAME ` FRANK WATSON OWNER ADDRESS rSAME TEL 774-487-0124 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:.! ; PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS- 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 � w INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IA NO Li 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 a P nine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C\ ..,..� PLUMBER-GASFITTER NAME LSTEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP MGF JP JGF LPGI CORPORATION J# 3281C PARTNERSHIP, -#: LLC # COMPANY NAME:E.F.WINSLOW PLUMBING&HEATING ADDRESS L8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP j 02664 ]TEL 508-394-7778 FAX L508-394 8256 CELL,N/A JEMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents y — Office of Investigations ' 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.III 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. III 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.❑ 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#I. 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 •��the ins�nd-penalties of perjury that the information provided above is true and correct. Signature: 7' 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 2.1=1Building Department 3.1=I City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: 4. www.mass.gov/dia