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HomeMy WebLinkAboutBLDP&G-20-001143 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK M="- YARMOUTH� CITY/TOWN MA DATE 08/27/2019 PERMIT#/144/2-g0"60/(Y3 JOBSITE ADDRESS 485 WEST YARMOUTH ROAD OWNER'S NAME JOHNSON,WILLIAM OWNER ADDRESS WEST YARMOUTH TEL 508.258.0920 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED:YES❑ NO[a' FIXTURES 7 FLOOR-. 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 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES g NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABIUTY INSURANCE POLICY g OTHER TYPE OF INDEMNITY 0 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 D 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 Iru 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. nc. PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP 0 JP❑ CORPORATION g# 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 accountspavablel6Zefwinslow.com �/ WORK ORDER 511126$40.00 L/e'/ 4b t,a ......... The Common-Wealth of Massachusetts , .0,74........... 1 ,..i.. Department of IndustrialAccidents tif Miiiirit9; 1 1 Congress Street, Suite 100 m Boston, MA 02114-2017 . %,.--.. .--.7 -ckliz‘v.1 _ _ www.moss.govAlia Artxkers'-Compensation Insurance,Affidavit: BuildersiContractors/Electricians/Plumbers. TO BE FILED WITH THE PERMIrTINt AUTHORITY. Applicant Information Please Print Legibly Name (BusinessiOrganization/Individual):E.F. WINSLOW PLUMBINGA 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: Typepfproject (required): 1.01 am a employer with 8 8 employees(full andior part-time).* 7. El New construction 2,O.I am,a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity. [No workers' comp. insurance required.] . 3.1:j I am a homeowner doing all work myself.. [No workers'comp. insurance required.il 9 D Demolition 10 Ei Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet . . These sub-contractors have employees and have workers' comp, insuranee.t 13 0 Roof repairs 6.0 We area Corporation-and itsofficershave exercised their tight of exemptiOnier1401-,e. 14.0 Other 152, §1(4),and we have no employees. [No workers' comp. insurance requireci:j ''"Any applicant that checks box 41 must also fill out the Section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating,they are doing all and then hire outside contractors must submit a new affidavit indicating such. TContraetors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have ernployces. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY — Policy# or Self-ina. Lic.. #:1909A 01/01/2020 Expiration Date: Job Site Address: • City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage,as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to'S1,500.00 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insuranoe coverage verification. I do hereby certiO and -pai s nd pen Ities of perjury that the inforniation provided above is true and correct. Signature: I" "". II ____ Date: 'Phone 4:5°8-3947778 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): I. Board of Health 2.'BUilding Department 3..Cifyillilit Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person:. - Phone#. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 08/27/7014 PERMIT#/ /7—d'O 007(�� JOBSITE ADDRESS 485 WEST YARMOUTH ROAD OWNER'S NAME JOHNSON,WILLIAM G OWNER ADDRESS WEST YARMOUTH TEL 508.258.0920 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL 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 1 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❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY[v7 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 t nd 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 com '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 ATU E MP g MGF❑ JP❑ JGF❑ LPG'❑ 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 511126$40.00 ' D f 0 .a'S The Commonwealth of Massachusetts rmi- =_+ f 1 iri Department of IndustrialAccidents f �.� —•i• ._�.r Jj� 1 Congress Stree4 Suite 100 .� �_ Boston, MA OZ 14- 017 t ;,�; w w.mass.gavldia Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers.. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information : Please Print Legibly. Name.:(Business/Organization/Individual):E.F. WINSLOW PLUMBING & HEATING CO., INC Address:8 REARDON`CIRCLE City/State/Zip:SOUTH YARMOUTH:, MA 02664 Phone #:50.8'394-7778 Are you an employer? Check the appropriate box: Type.of project (required): LE I am a employer with ,V employees(full and/or part-time).* 7. ❑.New construction 2,121.I am.a sole proprietor or partnership and have no employees working for me in anycapacity. [No.workers' camp. insurance required:] g Remodeling P tY• p 3.0 I am a'homeowner doing:all work myself. [No•workers'comp._insurance required.11 . ❑9 Demolition. 4.0 i am a homeowner and will be.:hirin corttractors to conduct ail work on ra 10 Q Building addition g my property., I wilt ensure that all contractors either have workers' compensation insurance or are sole 1 1.0 Electrical repairs or additions proprietors with no employees: 12.0 Numbing repairs or additions 5.0 I am a general contractor and I have>hired the sub-contractors listed on the attached sheet: These sub-contractors have employees and have workers' comp, insurance: 1 Ro©f repairs 6. We area corporation and its officers have exercised their right of exemption per-MGL;a; l •Q Other I52,§1(4),and we have:no.eiitployees. No workers' comp. insurance required.] ''''Any applicant that checks.box#I must also fill out the section:below showing their workers'corripensation policy information. t Homeowners who submit this affidavit indicating they are doing all-work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing'the name of the sub-contractors and state whether or not those entities have. employees: If the sub-contractors have employees,they must provide their workers' comp.policy number. I am an employer that is providing workers' compensation insurance for.. my employees. Below is the policy and job site information. .insurance Companyame_ARROW MUTUAL INSURANCE COMPANY • 1909A 01101/2020 oCey # or Self ins: Lxc. #: Expiration Date: Job Site Address: • City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showingthe policy number and expiration date). Failure- to sec is coverage-_as requi ed un-er MGL c., 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fort of a STOP WORK ORDER and a fine of up=to $250.00 a day against the violator. A copy of this statement may be forwarded:to the Office of Investigations of the DIA for insurance coverage verification. I do hereby Certify wit : 4crpai s ndpen lties of perjury that the information provided above is true and correct Signature: I - .�,,.04 Date: Phone#:5°8.394-7778 Official use only. Do not write in this area, to be completed by city or 1011.11 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#: