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HomeMy WebLinkAboutBldp-22-000441 { 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ce CITY YARMOUTH MA DATE 7/23/21 PERMIT# BLDP-22-000441 e' JOBSITE ADDRESS 5 AUTUMN DR OWNERS NAME ANISH WAYNE A P OWNER ADDRESS ANISH LINDA S 22 BEACH ST MILLBURY,MA 01527 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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❑ NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY❑ BOND El 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 ❑ 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 ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES e I i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK U'�' CITY YARMOUTH iMA DATE July 23,2021 PERMIT# BLDP-22 000441 JOBSITE ADDRESS 5 AUTUMN DR OWNER'S NAME ANISH WAYNE A G OWNER ADDRESS ANISH LINDA S 22 BEACH ST MILLBURY MA 01527 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 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/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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITYD 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 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC El# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsna,efwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i'!•_ul=:Z CITY l I;r�rrtoe11' I MA DATE 7� y./Z ( PERMIT# CSC O i'. l-1-L . `t`t/ JOBSITEADDRESS Avhy v7 Or 5, Y„, ✓pi ` OWNER'S NAME_iiVkve__Ilstr5y ___________ 1 POWNER ADDRESS Zti 13 utct-t 5't (1' of 2 1 TEI60$$6 5 I60 i.l I FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[l EDUCATIONAL 0 RESIDENTIAL(T - PRINT CLEARLY NEW:DI RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 01 NOD FIXTURES 7 FLOOR-► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB , _ : _ I - I 1 CROSS CONNECTION DEVICE 1= „1,_,,,_„--. i ''L-� ! '�' I` "� - DEDICATED DEDICATED SPECIAL GAS/OIL/SAND SYSTEMM - Mir i L ., WI DEDICATED GREASE SYSTEM -;J'----1 =- -,�_ �- �i --w',__-_1-_ I- .1111M -,-- .__ ,._ 1 DEDICATED GRAY WATER SYSTEM �V j l I DEDICATED WATER RECYCLE SYSTEM a I(,,, %_._,. L 1 ,.,�,- DISHWASHER , - '___.I _ I _ DRINKING FOUNTAIN ' _____ _._;_ __ . ' ,_.,:,,.,. i `-,. ( ,,,_1 FOOD DISPOSER ? ___ FLOOR/AREA DRAIN MillA., L II__F. — ID I INTERCEPTOR(INTERIOR) MI i i - . i. `li_ L-_J . KITCHEN SINK hJI______{; _ .i; _ l LAVATORY ltii _V ROOF DRAIN SHOWER STALL I 1_ - ---- I .�---I I SERVICE/MOP SINK _ TOILET I um URINAL I -- I � _ - ! M'I � -.--' WASHING MACHINE CONNECTION _ � � ' ` -�,--__: .. i..� .--� - it ' _. a.-- WATER HEATER ALL TYPES I _._._] __.-' __._: _____IL__ . WATER PIPING I ----�--i __ -�.-_- 'L-:�-_illl�l -----j - -- l -,=-..�I � �-.__' OTHER ._ r I ERE - '‘ .1 _in . I it IN INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ii IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY O OTHER TYPE OF INDEMNITY 0 BOND ID 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 U 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' ' "i -*'.,a -S---' PLUMBER'S NAME I STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP�1 JP i CORPORATION El# 3281C PARTNERSHIP I# __. J LLC1 _;I# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS J8 REARDON CIRCLE p CITY SOUTH YARMOUTH STATE[ MA I ZIP 102664 1 TEL 1508-394-7778 1 N FAX F508-394-82561 CELL[N/A _1 EMAIL INSPECTIONS@EFWINSLOW.COM V — _ ^1 The Commonwealth.of Massachusetts Department of Industrial Accidents ' Office of Investigations Lafayette City Center ), 2Avenue de Lafayette,Boston,MA 02111-1750 .r s 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. ❑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.n 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.U We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.11 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. Lie.#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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' e the ins and penalties of perjury that the information provided above is true and correct. Signature: Date: 01/02/2021 Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1.0Board of Health 2.❑Building Department 3.0 City/Town Clerk 4.0Licensing Board 5D Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r _ 'E1_s CITY MA DATE J j PERMIT# JOBSITE ADDRESSI5Aubma YKryns vicu _a OWNER'S NAME wpyri G TEL50$ ,6_.5. t f.. FAX OWNER ADDRESS _l2 ��rn.0 In_��u_�!11.�4t,�fl�1�...����_�.__...__� TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES El NOD APPLIANCES 1 FLOORS-4 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 �. �_.._...v FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER ( J LABORATORY COCKS �_..___ ._ .... __, -• MAKEUP AIR UNIT OVEN POOL HEATER Y_ .. _,._.._ 'J..— __.... 1_._- __..41_ __.. ROOM 1 SPACE HEATER - L _ �.�„ • 1h I -- ROOF TOP UNIT a . ._n_....0_ _ -- _a TEST v �_ UNIT HEATER ---- TN-RENTED ROOM HEATER WATER HEATER -_. _._ _ _ __ OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO Q • I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY pi OTHER TYPE 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. CHECK ONE ONLY: OWNER _[�-� AGENT ,E 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 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 rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP LA MGF® JP D JGF D LPG]D CORPORATION ET 3281C PARTNERSHIP®# , LLC LPL_ I COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE v as 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 • Department oflndustrialAccidents `'t Office of Investigations z Lafayette City Center �t� _ 2Avenue de Lafayette,Boston,MA 02111-1750 • 1/4.: wwly.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. ❑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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care 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- e the ins and penalties of perjury that the information provided above is true and correct Signature: r .•«�1"--- 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 2.0 Building Department 3.0 City/Town Clerk 4.11Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: • www.mass.gov/dia