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Home My WebLink AboutBLDP&G-20-005362 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK li ®„ �_ CITY YARMOUTH MA DATE 04/01/20 ----1 PERMIT 5'JJ PERMIT# - 'IZ JOBSITE ADDRESS [300 BUCK ISLAND ROAD,UNIT 15B OWNER'S NAMEI KNAPP,DONNA POWNER ADDRESS !ST YARMOUTH TEL 617.872.4986 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW RENOVATION -_M{ REPLACEMENT: PLANS SUBMITTE D: YES_ NOD FIXTURES Z FLOOR-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB milt 1 CROSS CONNECTION DEVICE i DEDICATED SPECIAL WASTE SYSTEM _ E DEDICATED GAS/OIUSAND SYSTEM 1111111 MU !NMI IIIIII NM MR', , DEDICATED GREASE SYSTEM INS MIN NM NIMMEMII Mr : . DEDICATED GRAY WATER SYSTEM Slig Miff 111111 MINIMINIM11111111.- .....mmom � DEDICATED DISHWASHER WATER RECYCLE SYSTEM ME MI IMI MI MM. IIIIMIIIIIIMFIIMI ' ' ., DRINKING FOUNTAIN 1 FOOD DISPOSER FLOOR/AREA DRAIN I INTERCEPTOR(INTERIOR) KITCHEN SINK M... Il pi ii ; dui . .. , LAVATORY o= NE ROOF DRAIN mm amism SHOWER STALL 1111.1110111111111M SERVICE I MOP SINK TOILET URINAL m NEI WASHING MACHINE CONNECTION IIIMIM ;' Will. J WATER HEATER ALL TYPES I M®, .._ WATER PIPING I"OTHER � l l 1MO 523550$40 00 INSURANCE COVERAGE: I have a current liabilit'Linsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ril NO ral IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY' i OTHER TYPE 0=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 eitered regarding this application are truer 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 c�iwith II ertine pro'isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW ILICENSE# 12298 I SIGNATURE ~�MPH JP:.1 CORPORATION psi# 3281C PARTNERSHIP[# LLCD# I COMPANY NAME E.F 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 1 EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents R_ Office of Investigations i*t t Lafayette City Center II 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. ❑ 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#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. / 01/02/2020 Signature: Y '` .......`— Date: 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 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �• 'f - : CITY YARMOUTH MA DATE 04/01/20 PERMIT# �^ et) . `. JOBSITE ADDRESS^300 BUCK ISLAND ROAD,UNIT 15B OWNER'S NAME KNAPP,DONNA., GOWNER ADDRESS WEST YARMOUTH TE1L817.872.4986 FAX[ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLYNEW:i ' RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO', APPLIANCES-1 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 DRYEP. 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 1 OTHER WORK ORDER 523550$40.00 INSURANCE COVERAGE I have a current liabilkinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 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 aVP�ertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /,, PLUMBER-GASFITTER NAME I STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP '- MGF: JP JGF LPG'; j CORPORATION #L3281 C PARTNERSHIP # LLC # COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS!8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE M ZIP;02664 TEL508-394-7778 FAX 508 394 8256 CELL N/A EMAIL; INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts w Department of Industrial Accidents q - 9 Office of Investigations (. . 1t j 5, 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): 1.11] 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]** 11.1] 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 i of the in a d 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): 1.0Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia