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Home My WebLink AboutBLDP-23-10695 a , ; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK „w=_ /l06t5'C ®�'= CITY YARMOUTH I MA DATE 5/11/23 PERMIT#Sz-0,-Z3— SeCkfs it!! JOBSITE ADDRESS 481 BUCK ISLAND RD BUILDING 1.9 T I OWNER'S NAME PAUL DOLAN i P nA-A OWNER ADDRESS SAME 1 TEL 617-680-7393 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:Q PLANS SUBMITTED: YES® NOQ FIXTURES 1 FLOOR—. BSM 1 2 3 4 I 5 6 7 8 1 9 10 11 12 13 1 14 BATHTUB , _ jj CROSS CONNECTION DEVICE iiii Ma DEDICATED SPECIAL WASTE SYSTEM ' DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN mom FOOD DISPOSER IIIIIIFIIIIIIFIIIIINIIIIIMIIIIIMMNIIIIII FLOOR/AREA DRAIN _ .. Y INTERCEPTOR(INTERIOR) ....... ��, 1 ,�, KITCHEN SINK LAVATORY PIM MN I ow agt I ROOF DRAIN SHOWER STALL ® _ ' r - r -'*- -...- v .r - r ,w- . SERVICE/MOP SINK iiii TOILET URINAL Oilli WASHING MACHINE CONNECTION WATER HEATER ALL TYPES inn iiii WATER PIPING n r - r OTHER ,. ..�,- y r m . 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 0 OTHER TYPE OF INDEMNITY ® BOND 0 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 0 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 r 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 co li wit II ertine proYisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MPD JP❑ CORPORATION ID# 3281C 'PARTNERSHIP®# LLC[J#1, I COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 102664 J TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM r I ni. The Commonwealth of Massachusetts a Department of Industrial Accidents r ►�, Office of Investigations Of. Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 �t 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): 1.0 I am a employer with 120 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.0 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. El 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]** 4.ElWe are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.❑ 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:23 COMMONWEALTH AVENUE City/State/Zip: CHESTNUT HILL, MA 02467 Policy#or Self-ins. Lic. #2019A Expiration Date:01/01/2024 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 • ej the ins and penalties of perjury that the information provided above is true and correct. ' // 01/01/2023 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): l.DBoard of Health 2.1=1 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �=_:` , •i ii -a Gig; CITY YARMOUTH MA DATE 5/11/23 PERMIT# ' Z� ` I U JOBSITE ADDRESS 481 BUCK ISLAND ROAD BUILDING.9-IM4OWNER'S NAME PAUL DOLAN G OWNER ADDRESS SAME -I -44e- TEL 617-680-7393 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL LI EDUCATIONAL Ll RESIDENTIAL PRINT CLEARLY NEW:El RENOVATION:Li REPLACEMENT:El PLANS SUBMITTED: YES Li NO El APPLIANCES-1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i BOOSTER ,M, 1:-MMX-R IN: CONVERSION BURNER i WE COOK STOVE saisimmaimumeiniimultaiimmiamisaimiammentaissit DIRECT DRYER VENT HEATER , f .• FIREPLACE FRYOLATOR FURNACE womiliorair _ e asi GENERATOR ' 1111- ;: . GRILLE 'M1--MMIIIVMIIIMI,S1111M1111111111M111111 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ! ' m _ '. i MI 0.11111111111.1. OVEN 111111111011111111111111 a .. d -0111 Mal POOL HEATER 11111111.11111.111111 M. :Mail ROOM/SPACE HEATER mg wpm a . '�N BE F ROOF TOP UNIT y= Imam TEST - _ _ Ns I=use mum me UNIT HEATER ; .. I - UNVENTED ROOM HEATER �.i ilI rill*.UW4 me ii, WATER HEATER OE--Mal-AM MK ON-I OM iliRaiii inil INN OTHER 6 _ w m .. . . ��ri f' II �,. .t� i WitaiMII.!_. . . . .. _ .o 11111 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LrJ NO LI I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Li OTHER TYPE 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 Li AGENT Li 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 compliaanc a YP�ertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 71 f/ ` // 7' �'^-'' PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 1 i SIGNATURE MP Lj MGF U JP® JGF_.. LPGI 0 CORPORATION LI# 3281C PARTNERSHIP LJ# LLC U#[ COMPANY NAME:i E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA J ZIP 02664 TEL 508-394-7778 FAX[608-394-8256 1 CELL N/A EMAIL!INSPECTIONS@EFWINSLOW.COM �� \ The Commonwealth of Massachusetts =z o Department of Industrial Accidents x Office of Investigations sIII+ABlt A, ! Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 NO'' 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 120 employees (full and/ 5. El 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 3.0 We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *My 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:23 COMMONWEALTH AVENUE City/State/Zip: CHESTNUT HILL, MA 02467 Policy#or Self-ins. Lic. #2019A Expiration Date:01/01/2024 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 ce the ins and penalties of perjury that the information provided above is true and correct. ' / 01/01/2023 Signature: 1' "` ..—.1...,.. 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): I.❑Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia