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HomeMy WebLinkAboutBLDP-21-006129 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 4/22/21 PERMIT# BLDP-21-006129 I= � JOBSITE ADDRESS 11 VIRGINIA ST OWNERS NAME JOSEPH PIERRE P OWNER ADDRESS JOSEPH PATRICIA 181 LEBANON MT RD PITTSFIELD,MA 01210 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ 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 El NO El 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. 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 12298 SIGNATURE MP © JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA 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 PERMIT FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �;_"1�_ CITY L__.-_,. _ IAL ._ _____ ......._..__.,—_.�...,.�., �.__ MA DATE L I .....1. _.._ PERMIT# JOBSITE ADDRESS ll U:d ;q;ot S+ V 1-t a/mC✓I-ti OWNER'S NAME P 2JPQ44YPE WNER ADD�DR�ESS MO_. L�� aiioil AAQL,'1,'f-ct tcy t ReSi_Pf,Q!] TEL)4 t3_ . '6 113 0 ) �FAXI,__�_�_,_-._,.._�. TYPE OR OCOMMERCIAL 0 EDUCATIONAL D RESIDENTIAL[r- PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES® NO0 FIXTURES 1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I 1 _ 1 .'L___ ] CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM igig mg1i j mg ��fl '[ id Illi DEDICATED GAS/011../SAND SYSTEM _I1 I_ W III II 1 DEDICATED •AWATER SYSTEM d DEDICATED i ftiourtungromftinipm I ice? ' I DRINKING FOUNTAIN _ 1 ; I I FLOOR/AREA DRAIN in_m___ , _ , _ ,_ _ . INTERCEPTOR(INTERIOR) nk ___ 1 _ 1-- I , — — KITCFIEN SINK ,1111111111 NW Mat MR LAVATORY I F'.___ _INI "I II [ J I l I _ ROOF DRAIN —:111111111.11111111111111•11.01111 I 1. r I , — __ SHOWER STALL I1 I I 1[ 1 'MI I iI II [M1 SERVICE I MOP SINK I1III 'IIIf1[ `I WASHING MACHINE CONNECTION Nana'=====ifli"'"inn . . . f l f ( (TOILET 111111111,1111111111111111,MN rarillal MI 1111101111ta Ilan 1111111111111t WATER HEATER ALL TYPES ! 1 AMIE _ 1 ( f l f ' W OTHER II Ii—. iI I I I I I�I I IUImaim( WI ow NW WIN T I J A I L _ I _ _�I I ; -_ll ___! 1 .__ . _— _ r. ____ _ ..__ _ _7I I f IUI I IL I_L I I.. _ I 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES'D NO U 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 [ 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 D 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 coli with II ertine pro'lsioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / .?, ...` .44.44,......— PLUMBER'S NAME L STEPHEN WINSLOW 'LICENSE# 12298 SIGNATURE MPI JP El CORPORATION:3# 3281C PARTNERSHIP[i# 1LLC I__ # ____-....-_.__-._.._-._._s COMPANY NAME LE.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE 1 r CITY SOUTH YARMOUTH __ _ STATE MA I ZIP 102664 1 TEL x508-394-7778 _1 ' v FAX x508-394-8256 J CELL N/A 1 EMAIL INSPECTIONS@EFWINSLOW.COM _ 1 The Commonwealth of Massachusetts Department of IndustrialAccidents 1—( 7 l Office of Investigations -- i— Lafayette City Center - "� r 2 Avenue de Lafayette,Boston,MA 02111-1750 �r, �'`�� 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_90 employees (full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.0 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. [No workers' comp. insurance required] 8. ❑Non profit 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.0 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: 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 cer ' e theins and penalties of perjury that the information provided above is true and correct. . / Signature: r "` ../..-.— Date: 01/02/2021 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): 1.OBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4. Licensing Board 5.[]Selectmen's Office 6.0Other Contact Person: Phone#: www.mass.gov/dia