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Home My WebLink AboutBLDP&G-20-001005 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK E ma's` - CITY/TOWN YARMOUTH MA DATE 08/19/2019 PERMIT#/�/7 0—cV BOO li_ JOBSITE ADDRESS 16 SACHEM PATH OWNER'S NAME HARDING,GEORGE OWNER ADDRESS WEST YARMOUTH TEL 978.337.4556 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: ® PLANS SUBMITTED: YES❑ NO[' 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 DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING __ OTHER 4- INSURANCE INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ' NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [V7 OTHER TYPE OF 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 ar rue and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP RI' JP❑ CORPORATION [ '# 3281C PARTNERSHIP❑# LLC❑# COMPANY NAME EF WINSLOW PLUMBING& HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayableAefwinslow.com WORK ORDER 510720$40.00 �� The CommonlettoJMassachusetts r:d' }11 i</ Departmentoflnilus Il.AWidents c - I 1 Congress Street,Suite 100 gif® a Boston,MA 02114-2017 . :,. - ,,�� www.mass.gov/dia Workers'"Compensation Insurance Affidavit:Builders/Contractors/Eleetricians/Plumbers. TO'BE PILED WITH THE PERMITTING AUTHORITY. I1"DMileant Inforr ation Please Print'Legibly (g {tottj �:EF:`WINSLOW PLUM N;�Iiae :BING-&HEATING CO., INC �8 :,' CIRG1E Address: Gity/State/Zip:SC)UTH YARMOUTH, MA 02664 phone#:508-394-7778 Are you an employer?Caa !pproptte.box: Type,of project(required): t. am a empioyerwith 88 cmployfoes doll and or part-tine).^ 7. El New construction .I am a"soleproprietor or partnership anlibave no employees working for ln.- �`� 8. [)Remodeling any capacity,No workers!comp inatihance required.] ;Q lam hdha' 10 i lingta'l*thyself•[No workers'comp.insurance eenoiteti.`t 9. ❑Demolition 10 0 Building addition 4:0 I am a hbmeownelxand will ittiliiring contractors to conduct all work on my property. I will ensure that all contractors,elitier have workers'compensation insurance or arc sole 1 1:0 Electrical repairs or.additions ProPrietots with no.employees. 12.0 Plumbing repairs or additions 5.❑I adr t; ierat con �ired.:the sub-contractors listed on the attached- 13.a Raof,repairs These sub-contragfi�Lll �Yad have Wort lt'comp.insurance 6.0 W• oera try exercised their right.o i tp 'l tfii;:ih- 14.0Other 15241 go;ettiploycas No workers comp,insurance required:] :. y sPlilitia ifthattle l'r, 1'must also fill out the eeahon,betow showing then workers'compensation pohtcy,,i„.„�Lrmation. t.An Homeowners who submit this affidavit Indicating they are d tlg.alll:wprk and then hire outside contractors mustttuwrnt-a new.aff itkivit`ind'tcating such. tcontraclbrs that check this box must attached an additional shetrithOWjelgthejtsatte,or the sub-contractors;at'idatate'wl ether or not those entities have employees, lithe sub-contractors have employees,the,,must iB'1 eer Woiltete comp.policy number, I wit apt. nployer that is providing workers'compensation insurance for my employees,. Belaw'Is-the policy'and job site infnrnation instil'iahtol3*itYpany Name:ARROW MUTUAL INSURANCE COMPANY "alioy#or Self ins.Lie.#:1909A Expiration Date:°1/°1/2020 Job Site Address: City/Staie/Zip: A ttach a copy of the workers,compensation policy declaration.page(showing"the policy number:and expiration date). T"41,1; ;Igo secure :.ovelase_as required under MCL c. 1,52,§25A is a criminal violation punishable by a fine t:l.:to S1,500 00 and&'one-'ear imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine.of up to$250 00 a day sga natttkt*olator.A copy of this statement may be forwarded to the Office of Investigations of the DIA fl 1 u suranoe coverage verifieatioti. I do hereby certify unai s nti pen [ties of perjury that the information provided above is true and comet. Signature: Q.717" "" Date: hbne#508-394-7778 Off ciatiseonly. Do not write inutitis area,to be completed ly"cityor town o fielaL, City orItor ant_ Permit/Lkcefl e# Issuing Authority(circle one): 1.Board;of Health 2.'Btiilding Depttt`tmmeft 3sCity/Town Clerk:: 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:. Phone#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK YARMOUTH Ty MA DATE 08/19/2019 PERMIT#1/LW-PO.729/OaS �.16SITE ADDRESS 16 SACHEM PATH OWNER'S NAME HARDING,GEORGE VT OWNER ADDRESS WEST YARMOUTH TEL 978.337.4556 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 21 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 1GRILLE -INFRARED HEATER LLABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER 1 _ WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IA NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [v' 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 tru -and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compl ice with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE# 12298 SIGNATURE MP g MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION g# 3281 C PARTNERSHIP❑# LLC❑# COMPANY NAME EF WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com WORK ORDER 510720$40.00 t ` ttF -- The Comfttealth o M �_, — f Massachusetts y e �,,�1- t Depai ti riflndustra dents' '_:4111i—-v 1.;Congress Street,Sum 100 r= •.Roston,MA 02114-2017 . " . ,,,a www.mass.gav/dia Workers'Compensation Insurance Affidavit:Builders/Contractdrs/Electricians/plumbers. TO' IILEiD WITH THE PERMITTING AUTHORITY. Applicant Information Please Print'Legibly Name(Business/Organization/Individual;):E.F.WINSLOW PLUAPti�ilGIt PATING,CO., INC Address:8 REARDON'ORek ei ;4.0Y-I ARMOUTN, MA 02654 Phone#:508=394-7778 Atl¢ u",empI4 r?Check the appropriate,box: Type,.of project(required): I:LW ai a emplerwith 8 employees(full and/or part-time). 7. D New construction IIIark aiO $pTietor or partnership bavciqu�;em4$1 tivorking forme in. 8. Remodeling y y eep5 4io'worlmrs'Gump.utsutantlb ce hired.) . I am a'lmmeowner domgall'Work,myself,[ttlastotkers'comp.insurance required.)l 9. 0 Demolition 1 am a homeowner and will be>hirin contraotorsto conduct ill work on my10❑Building addition 4. ❑ _. g property. I will ensure that all contractorp,eitlierhave workers'compensation insurance or arc sole 11.❑Electrical repairs oradditions proprietors with no cmployairs: 12.❑Plumbing repairs or additions 51:1 lam a gerteralcontrectoran lshavehircd the sub-contractoprlisted on the attached Sheets 1 Roof repairs These sub-contractors hav ployces and have workers'{ ,huntrancc:k 6. We arc s to oration and` have exercised theirr'ei t of Nl(ft;,a, `, 14.❑Ot or ❑ rP $�� $tt A-pa'' 152,§1(4),and we have no ployees.[No workers'comp.insurance tegli red.J •'"Any applicant that checks box#1 must also fill out the section below showing theft wants'"compensation policy information. t Homeowners who submit this affidavit indicating they ate doing al►•work and Umatilla outsidecontractors must submit a new affidavit indicating such. tContractors that-eicglethis box must attached an additional sheet showing t#canape-of the sub-contractors and state whether or not those entities have emplpycccs.'If then untractors have employees,they must provide their woritpt5 comp.policy number. ---ass I am-r( p : � compensationformy p y f Y ttti%10►ta;R' /iaptt ,�, t�►!arlEe .lnsal►Ytnce ern io ees. Belorw' s the; Ik and job site info, ai!hfl& Institvidt, zt ;dhy Name:ARROW MUTUAL INSURANCE COMPANY Policy`#or Self-ins.fie,#l139A Expiration Date:01/01/2020 JobSite Address: < City/State/Zip: Attach a copy of the workers'compensation policy declatraliton page Mowing the policy number and expiration date-: Pat*_to secure coverage,as required under MGL c. 1552,§25A is a criminal violation punishable by a fine up to$1,500 00. ansl one-year imprisonment,.as well as civil penalties in the forth of a STOP WORK ORDER and a fine of up'to$250,0b'a' dayFt‘the violator.A copy of this statement may be forwarded to the bite of Investigations of the DIA for insurances 'ftcation.GC1 t.,u .c, I4,. cerh;/y and s nd pen fries of perjury thatthe-Inform ation provided above Is true and correct. 7ai ,/ �+ -- Signature: n /+6._ Date: Phone#:508-394-7778 ti Official use only. Do not write in thitetrea,to be completed by city or town official'- City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other GOti'tttc't a oat Phone#