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Home My WebLink AboutBLDP-19-1203 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 0/ CITY' YARMOUTH MA DATE 8/28/18 PERMIT# BLDP-19-001203 1 JOBSITE ADDRESS 54 SCHOLL AVE OWNER'S NAME QUINN JOHN E ESTATE OF P OWNER ADDRESS MCGUINESS ANNE J EXECUTRIX 16 SUMMIT RD NAUGATUCK,CT EL • 06770 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:m 'PLANS SUBMITTED: YES❑ NO E FIXTURES 1 FLOORS—. RSM 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 SYSTE DISHWASHER DRINKING FOUNTAIN - FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINKI LAVATORY ROOF DRAIN • SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 1 WATER HEATER I. 1 WATER PIPING 1 OTHER 1 OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current Jiability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY m OTHER TYPE OF INDEMNITY 0 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 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. PLUMBER'S NAME Stephen Winslow LICENSE#2298 SIGNATURE MP 9 JP 0 CORPORATION ❑# PARTNERSHIP Ott LLC ❑# • COMPANY NAME STEPHEN A WNSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP [026641207 TEL FAX CELL EMAIL accountspayable@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No S THIS APPLICATION SERVE AS THE ❑ ❑ oeourc FEES S PERMIT# _ PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK s _Sr Yt{= CITY Waging/ L. MA DATEI /23 / /9 PERMIT C/3t •p-19" iv 0-0-7› _J3BSITEADDRESS 54 Schell Pvenve2Vi.r'nio/i.OWNER'S NAME gnarl MCPeleS4 p I 02p14;ADDRESS 6 c11rYtmi- act. A7Ail rAh/ck1 LT TELISO`37155315 1FAX TYPE OR OCCUPA CYTYPE COMMERCIAL EDUCATIONAL0 RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:[' PLANS SUBMITTED: YES NOW FIXTURES 1 FLOOR-' I BSM 1 2 1 3 .1 4 5 6 [ 7 j 8 J 9 10 11 12 L 13 J 14 BATHTUB L r r , CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ - DEDICATEDGAS/OIL/SANDSYSTEM _ . - ISM - - DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _ DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN NI I_ _ INTERCEPTOR(INTERIOR) KITCHEN SINK t. LAVATORY ROOF DRAIN SHOWER STALL _ _ _ SERVICE/MOP SINK • fr TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER l Veit Pal.19 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY W 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. C C— 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 a 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 pliance with all Pertinent provlsiqp of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / p V PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIG ATURE f-.1 MPO JP❑ CORPORATIONW# 3281C 1PARTNERSHIP0# LLCD# r L� COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE U' ` CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 ‘.0 4#. FAX 508-394-8256 CELL N/A EMAIL(accountspayablegefwinslow.com -jp �Y • Oa\ a W.. VV...111'1*Ir44.&I• J L's. o.n.n.Y14/.J .= Department ofIndustrial Accidents 1 _;Eli(I�=it Office of Investigations `°n-_ 600 Washington Street •'s itLa Boston,MA 02111 i www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please lease Print Legibly egibly I 1 Name(Business/Organization/Individual): E.f.WIA3Ow Q( .. 6In3 g Vito_h `e.) int, Address: '' keocton Circle- City/State/Zip: Sou 'cr',r,,,kn h{Pc Phone#: "06-399-11751 4-Are you an employer?Check the appropriate box: Type of project(required): 1 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 1.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 1.❑ 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' comp.insurance required.] 13.0 Other 1ny applicant that checks Mx#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. 1 l lsurance Company Name: eiut O2 .„-nrwG n to_ Cetnetvii Dlicy#or Self-ins.Lic.#: 1$al Ac • Expiration Date: 1-1 - aol9 :Is Site Address:a3 Cevvvvien.rr-epith A4"ei Cke44. 4' Ill City/State/Zip: Oar►CO ttach a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). iilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ;le 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 'up to$250.00 a da a:ainst the violator. Be advised ti.t a copy of this statement may be forwarded to the Office of vestigations • the DIA or insurai - overage veri j on. do hereby certify un • e aims a penalties o 'jury that the information provided above is true and correct. pnatuT:• Date: la)31 1211017! lone#: .51A-3t1• 777g Official use only. Do not write in this area,to be completed by city,or town official • • \�\ City or Town: • Permit/Licebse# " Issuing Authority(circle one): eN 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Othe • r \^\ Contact Person: • Phone#: (� �y