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Home My WebLink AboutBLDP&G-18-006596 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �{�/ =lii= CITY/TOWN YARMOUTH MA DATE 05/18/2018 PERMIT#/ A�1'441 z'f' JOBSITE ADDRESS 25 LONGFELLOW DRIVE OWNER'S NAME BALKAM OWNER ADDRESS YARMOUTHPORT TEL 508-385-4899 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL E7 PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:VI PLANS SUBMITTED:YES 0 NO[' FIXTURES 1 FLOOR-4 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 I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 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 g NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M' 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 are e 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 liance with all P�ent�f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP El JP❑ CORPORATION[2# 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(Etefwinslow.com (� WORK ORDER 473698$40.00 („�* L1 o Department of industrial ccataera ► Wi=4i Office of Investigations s —:61p 600 Washington Street �` s:v Boston,MA 02111 . www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information t— Please( Print Legibly Name(Business/Organization/Individual): s`• t�514v� QL1v`^biv'c 2 k- . r1 o A. `e.s Vri Address: rk. dn C.Irt1.i?... . City/State/Zip:_Soo Sfv\ CY'w,cr•l"r' t`&P Phone#: 5b- '3rl''i-'1'T7 SI Are you an employer?Check the appropriate box: Type of project(required): I am a employer with '70 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 7 Remodeling !.❑ I am a sole proprietor or parhier- listed on the attached sheet,t ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.0 Plumbing repairs or additions +.0 I am a homeowner doing all work � g § myself.[No workers' comp. c,152, I(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] lny applicant that checks boir#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors 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. tsurance Company Name: %.,.s {`k`I Iry cLA ,- sunk."Ce... Ce J 1--t they#or Self ins.Lic.�4: \' } Pr - Expiration Date: k—t — i�31 )b Site Address: 3 Grw"crn v ec-' i ` , Akk-e,, C Ar��`* ill\\ City/State/Zip: 0.)'-i 67 .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). aiiure 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 f up to$250.00 a da against the violator. Be advised ttt a copy of this statement may be forwarded to the Office of tvestigations the DIA for insurape/overage verif c tkon. i do hereby certify uncle), e ains ana penalties o ppeljufy that the information provided above is true and correct. ignatt fie: L.....-. <ti r Date: (a\3 i ! 'AO\er hone#: . )41+.i t''t' 7 77 g 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#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 17- CITY YARMOUTH MA DATE (15/1 R/2D1 fi PERMIT#/ /'-, dod3 7 JOBSITE ADDRESS 25 LONG FELLOW DRIVE OWNER'S NAME BALKAM GOWNER ADDRESS YARMOUTHPORT TEL 508-385-4899 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL g PRINT CLEARLY NEW:❑ 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 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 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 17 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY g 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 tr e 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 corn ' nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE# 1229 SIG ATURE MP[ ' MGF❑ JP❑ JGF❑ LPG' ❑ CORPORATION Q# 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 accountspayablep,efwinslow.com WORK ORDER $40.00 /9 R rl to 6- ! 1'I I y _* Department of industrial Aiccadenas '== =fi i Office of Investigations ---. - t =elil= 600 Washington Street • -7:` Boston, 102111 www.mass.gov/diva Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumberslease Print Legibly' Applicant Information � i Name(Business/Organization/Individual): `• \1�IA5 t 4v,.) QW°`^bi`'t0 LZ, (.1‹.a ) e_, je-it. f Address: ?` (kP 1 �l City/State/Zip: Soo Sfv\ rte,csJ " MA . Phone#: -YN-117 Are you an employer?Check the appropriate box: Type of project(required): 1 am a employer with '7C 4. ❑ I am a general contractor and 1 6. [l New construction employees(full and/or part-time).* have hired the sub-contractors attached sheet.F 7 El Remodeling ;,❑ I am a sole proprietor or partner- listed on theDemolition ship and have no employees These sub-contractors have 8. Es 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.] officers have exercised their ;,0 I am a homeowner doing all work . rightexemptionper of MGL 11.0 Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.11 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] thy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontraetots 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. , r tsurance Company Name: [�YYO• (`"\v v'•� 4 l /\SsU` A,.el C.e. \ aivN 'IL olicy#or Self-ins.Lic.#: \S AI A' - Expiration Date: tTi - aol`"7 ib Site Address:D3 Gr,crn JEQ t i-, A i.'y C :Ariv.A. In\\ City/State/Zip: c;; 4 467 .ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). adore to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a tie 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 f up to$250.00 a da a ainst the violator. Be advised kt a copy of this statement may be forwarded to the Office of westigations the DIA for insurne overage veri c Yon. i do hereby certify unir"!e j airs ana penalties o pe jay that the information provided above is true and correct Date (� l ' i tut`r l,-, f 0(e • hone#: .5tI`ik•.1c1`]- 777X Official use only. Do not write in this area,to be completed by cit)).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#: