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Home My WebLink AboutBLDP&G-18-005754 MASSAC4 iUSE1iTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK IT-ff CITY/TOWN SOUTH YARMOUTH MA DATE 04/10/2018 PERMIT —it—de y JOBSITE ADDRESS 55 ELDRIDGE ROAD OWNER'S NAME PIERRE MOCCALDI Gp6.27 Q P OWNER ADDRESS 1 SUNSET DRIVE, BURLINGTON, MA 01803 TEL 617.694.3942 FAX C), TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[' oPRINT PLANS SUBMITTED: YES❑ NO[I CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: [� 41 FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE ,o DEDICATED SPECIAL WASTE SYSTEM \0 DEDICATED GAS/OIL/SAND SYSTEM Vk 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 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES EX NO ❑ 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 LI 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 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 co fiance 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 M JP❑ CORPORATION 12# 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 accountspavable(a�efwinslow.com qb 02. r -r l ' Office of Investigations ti IT: _ 600 Washington Street .� � Boston,MA 02111 .�.a+ www.mass gov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information C ] n Please Print Legibly Name(Business/Organization/Individual):1E.c.W tevs(0,,.1 Y(k t-,36. ( 4 0.Q,Qr� Qs-)I elf, Address: ''j (eoi� �:rrr,�.l'- (� City/State/Zip: Soo lit Yv-nc 44'r is-Or Phone#: 50S-39 i-1`l?S • Are you an employer?Check the appropriate box: Type of project(required): ( I am a employer with •70 4. ❑I am a general contractor and I 6. ❑New construction .employees(full and/or part-time).' have hired the sub-contractors :.❑I am a sole proprietor or partner- listed on the attached sheet I 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9, 0 Building addition [No workers'comp.insurance 5. ❑We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions :.❑I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] toy applicant that checks be&#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit anew affidavit indicating such. :ontrectort that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees.Below is the policy and Job site formation. /n� _ A issuance Company Name: �IYyp„s [ 'J ko.A J`t vrA.✓i C2 Ce1tn,Fr1.1,-..1 olicy#or Self-ins.Lie.#: I a 1 A • Expiration Date: (—[" Don 1b Site Address: 3 Mov)urea-).1'h Ad-ey 0,e3AnA I'M\ City/State/Zip: CO t4 ie 7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a ne 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 Cup to$250.00 a da ainst the violator.Be advised t a copy of this statement maybe forwarded to the Office of vestigations the DIA for irss uape' trverage veri. on do hereby certify ur-aer iris an Jpenalties o pe t ury that the information provided above is true and correct. ignatur• (�r,� Date: ta�31)ROW hone it: ci,:A•3"1`.1-I77X Official use only.Do not write in this area,to be completed by city or town official • • City or Town: Permlt/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone d: T ._.,( MASSACH1 'SE' rS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1,:- ....,,, YARMOUTH DATE 04/10/2018 PERMIT # & OP ' ) /4 �� CITY SOUTH MA JOBSITE ADDRESS 55 ELDRIDGE ROAD OWNER'S NAME PIERRE MOCCALDI GOWNER ADDRESS 1 SUNSET DRIVE, BURLINGTON, MA 01803 TEL 617.694.3942 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL n RESIDENTIAL V K) PRINT 'Q CLEARLY NEW: RENOVATION: REPLACEMENT: V' PLANS SUBMITTED: YES NO �/ )\\d APPLIANCES -1 FLOORS-{ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER "1 BOOSTER CONVERSION BURNER \ COOK STOVE DIRECT VENT HEATER DRYER -- . FIREPLACE FRYOLATOR _ FURNACE N GENERATOR GRILLE INFRARED HEATER 1* LABORATORY COCKS MAKEUP AIR UNIT .. OVEN POOL HEATER _ - ROOM I SPACE HEATER ROOF TOP UNIT TEST ' UNIT HEATER UNVENTED ROOM HEATER _ WATER HEATER 1 , OTHER INSURANCE COVERAGE I have a current Iiabiliyinsurance 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 vi OTHER TYPE INDEMNITY n 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 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. diz- - ZI-L;i_ i.L.e,e;-1-6--- PLU M B E R-G AS F I NAME STEPHEN A. WINSLOW LICENSE # 12298 / SIGNATURE MP [' MGF JP n JGF 1 LPGI n 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 accountspayable@efwinslow.com 1_. —61- Office of Investigations ir Wil i600 Washington Street':,�.I a ', Boston,NIA 02111 www.rnass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumberslease Print Legibly Applicant Information P, //�� act Name(Business/Orgl1anization/Individual):e.c. rir,5IOW Q[ e.Jd.W1C a.vIfo-� y Cm-}icic. Address: ' QQPadt el C=i '�— 0 City/State/Zip: Soo h i"• '^u"I" MPc Phone#: 5011-3q4-1'77S1 Are you an employer?Check tine appropriate box: Type of project(required): I am a employer with 70 4. ❑I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractor 7 ❑Remodeling :.0 I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees 'These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5.0 We area corporation and its 10.❑Electrical repairs or additions required j officers have exercised their of exemption per MGL 11.0 Plumbing repairs or additions :,❑I a myself.[No workers'e doing all work right 152,§1(4),and we have no 12.0 Roof repairs an e r .] comp. employees. workers' insurance required.]t [No13.0 Other comp.insurance required.] my applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infomation. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontmetors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site formation. /� -_ (� isurance Company Name: ArYO,.s �i 1 .1 o. ,S h • , cstl'c+t'�Ce_ V1`-1 olicy#or Self-ins.Lic.#: \$a i /k • ,,tt Expiration Date: ('-[- )01-1 1bSiteAddress:�3 `Cnnr.trn v-ea�1"h Ad', C�.3k ' rn\\ City/State/Zip: O„1t4i,7 teach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a ne 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 Pup to$250.00 a da a ainst the violator.Be advised a t a copy of this statement maybe forwarded to the Office of ivastigations the MA for insurar?ef overage ven on. _i ( 1 / do hereby certify un elns an penalties o pe jay that the information provided above is true and correct. C.igna �r Date: 1'al 3 I 1 aoke' hone if: SO-35`1•'777X Official use only.Do not write in this area,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 Contact Person: Phone#: