The URL can be used to link to this page

Home My WebLink AboutBLDP-22-000683 t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK er, CITY YARMOUTH MA DATE 8/6/21 PERMIT# BLDP-22-000683 t I l JOBSITE ADDRESS 39 TEE WAY OWNER'S NAME Thomas Mcnamara P OWNER ADDRESS 39 TEE WAY SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL lal PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:m PLANS SUBMITTED: YES NO 0 FIXTURES • FLOORS— 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 SYSTE _ 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 1 WATER PIPING _ OTHER OTHER DESCRIPTION: 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 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 1Q298 SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP 0# LLC 0# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY IS YARMOUTH STATE IMA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES LfDI— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -�� . CITY ..�. r►assffn, . MA DATE 813 a PERMIT# Z Z- ra8� JOBSITE ADDRESS 13 c 'Tee (Oa , _r i 6,W,A OWNER'S NAME[Mai AA k,w&j POWNER ADDRESS 151 Eden pay K A' .rwaa.[2..1.2(e..Q j TEL -q4{r 'f FAX F------11 TYPE OR OCCUPANCY TYPE COMMERCIAL',_, ED CATIONAL El RESIDENTIAL["?/: PRINT CLEARLY NEW:® RENOVATION:D REPLACEMENT:COI PLANS SUBMITTED: YES® NO( FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB t �I `_ I — CROSS CONNECTION DEVICE - I`- _ ! rk� I t , I 111111111111I DEDICATED GASIOIUSAND SYSTEM DEDICATED SPECIAL WASTE SYSTEM !filigliputteinuppismoisma,DEDICATED GREASE SYSTEM `� xim � { 1DEDICATED GRAY WATER SYSTEM ! iitiR, DEDICATED WATER RECYCLE SYSTEM DISHWASHER111111111.11111) 'I ' t-` fDRINKING FOUNTAIN inimainistin - I im ... iFOOD DISPOSER mg migima wpm _FLOOR/AREA DRAIN mini isle 1111•11111111Mit ' MI ! 1111111 .11.111 int XlifillitINTERCEPTOR(INTERIOR OM MI 011N1 ,1 a ink .ausinLAVATORY Ill I 1 ROOF DRAIN SHOWER STALL1 SERVICE/MOP SINK t Iii- TOILET ___ _ , t,,__ ,, ___ i ___ ,_ ,41' _il _:: _ , WASHING MACHINE CONNECTION Amin imam new 1 ,mum jegoi . WATER HEATER ALL'TYPES 4 I i 1r "a 2 , s 111IMIIIIIIIIIIMIMIMMNmnliiIlUNBaiaitaliiiiiiiiiMiMgiliriliailliliailirRlilliIlliiMi .11.111111.11111111111.1.11.1.MiliWillinIFIWIWISKIIIIMMINNIMIONEMMIIIIM , I INSURANCE COVERAGE: ' I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY [1 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 [1 AGENT El 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 provisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, PLUMBER'S NAME STEPHEN WINSLOW r ». '".��- -_ LICENSE# 122981 SIGNATURE MP pi JP❑ CORPORATION[,,I#1 3281C 'PARTNERSHIP El#1 I LLC 0#1 J COMPANY NAME E,F.WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE CITY I SOUTH YARMOUTH 1 STATE r MA---i ZIP 02664 __ 1 TEL 1508-394-7778 FAX 508-394-8256 CELL N/A 1 EMAIL 1 INSPECTIONS@EFWINSLOW,COM I The Commonwealth of Massachusetts Department of Industrial Accidents 1=-- Office of Investigations =aiii1- Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 ',4,,, 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): 90 employees 1.® 1 am a employer with eesfull and/ 5. 0 Retail (P Y or part-time)." 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 8. 0 Non-profit [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 12.0Other with no employees. [No workers' comp. insurance req.] *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: City/State/Zip: Policy#or Self-ins. Lic. # 1964A Expiration Date:01/01/2022 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 ' e the ins and penalties of perjury that the information provided above is true and correct.01/02/2021 Signature: • ' " , .,.,./.. 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): II:Board of Health 2.D Building Department 3.0 City/Town Clerk 4.0Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia