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HomeMy WebLinkAboutBldp-28-000098 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK it r CITY YARMOUTH MA DATE 7/7/21 PERMIT# BLDP-22-000098 ' JOBSITE ADDRESS 28 APPLEBY RD OWNER'S NAME LOCHIATTO ANTHONY C P OWNER ADDRESS LOCHIATTO MARIANNE T 70 EDDY ST WEST NEWTON,MA 02165-2134 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW: El 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/OIUSAND 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 m NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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. 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 W298 SIGNATURE MP ❑ JP ❑ 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 f ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ El FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t CITY YARMOUTH al== MA DATE [July 07,2021 PERMIT# BLDP-22-000098 _ A JOBSITE ADDRESS 28 APPLEBY RD OWNER'S NAME LOCHIATTO ANTHONY C G OWNER ADDRESS LOCHIATTO MARIANNE T 70 EDDY ST WEST NEWTON MA 02165-2134 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ED 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 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 I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 © OTHER 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. 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-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsOefwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ El FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,„Yy�-i .._. -,.r.....v-..®.,mom "'I:1. � CITY E yarmouth ] MA DATE 7/01/2021 PERMIT# QLDC,- zz - c0009k — Y JOBSITE ADDRESS 28 a leb .road,westyarmouth 1 loch /y OWNER'S NAME �lochiatto/claflin GOWNER ADDRESS ! _ �. TEL 401.533.4662 TJFAX _ TPRINTR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 1 RESIDENTIAL L1 CLEARLY NEW:El, RENOVATION:Lj REPLACEMENT: PLANS SUBMITTED: YES, 1 NO ; APPLIANCES 7 FLOORS—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER IIIIII — all x BOOSTER I � i ' r— ii . la TM;.----.-.--'CONVERSION BURNER 4 j 9 -r""W ..."'t 7 t-..-,. [_._._._.vim r. r.-. ' --.-1 _ ._: (,_ .." �: . ,. COOK STOVE DIRECT VENT HEATER I I� 1i Q 9 DRYER I :�... ay. � � '_ :e 1 - r FIREPLACE 1 -1, 31 g1 ' FRYOLATOR '771 � iN. .p,_n. . �. _ 11-- 11 I. FURNACE ,.�' 9` 1 GENERATOR ' __. ` m_ �_h.�. .mF. . 1 GRILLE _.. . i' ' I I . �,. �. . �, ,,,. .' ,....., .... a' INFRARED HEATER I �- r I' LABORATORY COCKS ! ?l Sly � ..m:.e r- i.w_ t ..� I_ ,r MAKEUP AIR UNIT IIIIIISIIIIIIIIIIIIIIIIINI 11111111111111111111111011111111111111111MMOINI[MO OW OVEN j� �- li `[ 1 1 t POOL HEATER .__ �� .,:�m_,1II � i�.-. ' i I 1 �_.._.��],. ROOM/SPACE HEATER 1 -11.-- W__ _r - r__.._V ; t ROOF TOP UNIT i ri I 7 TEST r UNIT HEATER V 1 r 1 i --11----17 1 11 UNVENTED ROOM HEATER „ 1 WATER HEATER I 1 ' 1-�-- . _t ' ter---- ' OTHER. _ �__ ... t ..._ _ , urcawa .... � ,...:.-.-�.-., .., ..,. `.:..-. 5 is t. w10 555373$40.00.12 s IIIMIIIIIIIIIIIIIIIIINIIIIIIIIIIIIIIIIIIIIIIIIIIIIINIIIIIITIIIIMWNXIIIIIIIIIIII INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LA NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ,w 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 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 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 complianc a PP rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r ' !/ PLUMBER-GASFITTER NAME STEPHEN WINSLOW 1 LICENSE#t 12298 SIGNATURE MP 1W° MGF LJ JP 0 JGF Lj LPGI J CORPORATION D# 3281C 1 PARTNERSHIP EJ#J j LLC #j ..1 COMPANY NAME LE.F.WINSLOW PLUMBING&HEATING 'ADDRESS i 8 REARDON CIRCLE CITY I SOUTH YARMOUTH j STATE 1 MA I ZIP j 02664 1TEL;508-394-7778 m a FAX N/A�508-394-8256 I CELLI EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents WO—"? Office of Investigations } y , Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 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 90 employees (full and/ 5. ❑ 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.❑ 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]** 11.0Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 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: 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 /r the ins d penalties of perjury that the information provided above is true and correct. Signature: Y,f" '�-� 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.❑Board of Health 2.❑Building Department 3D City/Town Clerk 4.El Licensing Board 5.❑Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK er ti®v,nim IA w CITY yarmouth MA DATE 07/01/2021 PERMIT# 1 L 0 P- 7-1- —o0 X 9 8 JOBSITE ADDRESS 28 ap leby road,west yarmouth OWNER'S NAME lochiatto/claflin P OWNER ADDRESS _, TEL 401.533.4662 +FAX TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:Q REPLACEMENT:Q PLANS SUBMITTED: YES Q NOQ FIXTURES Z FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ( , i_ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM i .. _ jj .___ I__ ._ 1- ! I DEDICATED GAS/OIUSAND SYSTEM ' li DEDICATED GREASE SYSTEM _. . _ k e �. .. . 1 DEDICATED GRAY WATER SYSTEM I I DEDICATED WATER RECYCLE SYSTEM 1 e ii I ._ , i---- � --- I - . ., 1 r 1.DISHWASHER j DRINKING FOUNTAIN I ; it - . �!I ii INTERCEPTOR(INTERIOR)KITCHEN SINK , I !JI11111.1111111 SHOWER SERVICE/ F ••TOILET SINKi i _ i I II I:WATER HEATER ALL TYPES .1 , t WATER PIPING , w\o 555373$40.00 g12 I 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 0 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 0 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 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 with II ertine proyisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / r "' .....,o`i._ PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MPQ JP CORPORATION Q# 3281C PARTNERSHIP LLC©# COMPANY NAME E.F.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 INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts ` a Department of Industrial Accidents Office of Investigations Lafayette City Center 2Avenue de Lafayette, Boston,MA 02111-1750 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 90 employees (full and/ 5. ❑ 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. 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]** 11. Health Care 4.El We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 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: 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 the ins/and penalties of perjury that the information provided above is true and correct. Signature: Y '` •^--- 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): 10Board of Health 2.0 Building Department 30 City/Town Clerk 4.OLicensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia