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Home My WebLink AboutBLDP&G-18-007117 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _,�;1_ 9 CITY/TOWNSOUTH YARMOUTH MA DATE 06/11/2018 PERMIT# DP—i JOBSITE ADDRESS 21 LYN DALE ROAD OWNER'S NAME LINDA MARZANO OWNER ADDRESS 31 BEACH AVE. HULL, MA 02045 TEL 617.925.9110 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[i PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: 7 PLANS SUBMITTED: YES❑ NO[I 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/OIL/SAND 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(' NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LI 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 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 pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. AA PLUMBER'S NAME_ STEPHEN A.VVINSLOW LICENSE# 12298 SIG ATURE MP RI JP❑ CORPORATION[d# 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#475075 / PERMIT FEE-$40.00 , n l r� (�J '1u _. Department of 1ndustrtalAcctaeass 1`Irv:1_ Office of Investigations c_a 1i 600 Washington Street r. .�p @l- Boston,MA 02111 ;, r www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Legibly Applicant Information Name(Business/Organ izationitadividual):e..c•W tv\51 aw Q(ti'^^b et a.C'e0_\-:1 `e.,1.1f. o Address: 5c (Pnt� r.C:a .2— . 0 City/State/Zip: Soo kh " NA Phone#: '506.3R4-1'i7Sl Are�{y;ou an employer?Check the appropriate box: Type of project(required): 4'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 2 0 Remodeling :•❑I am a sole proprietor or partner- listed on the attached sheet.I ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5.0 We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their i.0 I am ahomeowner 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.] lay applicant that checks boo#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 cheek 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 in,employees.Below is the policy and job site !formation. /y t s � . isuranee Company Name: l lT O-.-/ C')r'J . 5 el f e- \ may olicy#or Self-ins.Lie.#: 1'is a] Pc Expiration Date: k-`[ Don ib Site Address: 3 ail‘,sree--(Th 1 C " 1kI\ City/State/Zip: 6),)'4ies7 Bach 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 f up to$250.00 a da a::lust the violator.Be advised / t a copy of this statement may be forwarded to the Office of ivestigations the DIA for insurape-,average very on. do hereby certify under:Lai:aims an penalties o p jury that the information provided above is true and correct. ignat&: — ,/t-^ Date: [DI 31'aO1 hone#: SO-25m-7 778 Official use only.Do not write in this area,to le 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 '` / - 7/I30: SOUTH YARMOUTH MA DATE 06/1 1/2018 PERMIT # / �� y r CITY JOBSITE ADDRESS 21 LYNDALE ROAD OWNER'S NAME LINDA MARZANO GOWNER ADDRESS 31 BEACH AVE. HULL, MA 02045 TEL 617.925.9110 FAX TYPE OCCUPANCY TYPE COMMERCIAL , EDUCATIONAL n RESIDENTIAL IA CLEARLY NEW: P RENOVATION: n REPLACEMENT: F. PLANS SUBMITTED: YES I NO 7/ APPLIANCES 1 FLOORS-4 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 L 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 U BOND u 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 n AGENT Pl 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 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 compli ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - 6-ft ZeilAiLc-Lt . PLUMBER-GASFI--TER NAME STEPHEN A. WINSLOW LICENSE # 12298 SIGNATURE MP iysMGF JP JGF LPGI CORPORATION VI# 3281C PARTNERSHIP Li # LLC 7 # 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 #475075 / PERMIT FEE- $40.00 LI CO IPr _ Department of indatstriaLAlccuten. t�— .i� l �Jfice of Investigations e=r!_ 600 Washington Street _;dI=4 Boston,MA 02111 o, www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information C t /� Please Print Legibly Name(Business/Organization/Individual):1.'F•W rrt\Sl OW YIVsniOine� 2_lAt0.�+1 Qa.,ieit Address: '' YZPod� CI oe- . 0 City/State/Zip: Soo ilh 'c -'c,A14 NPr Phone#: `501i-3G9.171 S' • Are you an employer?Check the appropriate box: Type of project(required): XI am a employer with "70 4.0 I am a general contractor and I 6. 0 New construction employees(full and/or part-time).' have hired the sub-contractors1. Remodeling 0 I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. El Building addition [No workers'comp.insurance 5.❑We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their i.❑I atn ahomeowner 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.] hey applicant that checks Mix ftl must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing ell work and then hire outside contractors must submit a new affidavit indicating such. :onbactors 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 andjob site formation. ____ (� tsurance Company Name: t/n��\T Y0•� C'')�� ..�nSttRA n CO_ VIM olicy#or Self-ins.Lie.#: 1' a1 A Expiration Date' t"[" Dori tb Site Address: 3 n e•'( y C$' IkIll City/state/Zip: f»y in? .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 f up to$250.00 a da inst the violator.Be advised at a copy of this statement may be forwarded to the Office of tvestigations the DIA for insurape overage veri .on. do hereby certb'uTair ns an penalties o p uty that the information provided above is true and correct. CC Date: 1al 311 ao16" ignatuT: 4�rn hone#: SO-31'1.777X Official use only.Do not write to 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#: