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HomeMy WebLinkAboutBldp-22-000867 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK c, CITY YARMOUTH MA DATE 8/16/21 PERMIT# BLDP-22-000867 I3 JOBSITE ADDRESS 668 ROUTE 28 OWNER'S NAME MANNING GERALD TR P OWNER ADDRESS THE PARKER RIVER REALTY TRUST 121 MAYFLOWER TERR SOUTH TEL YARMOUTH,MA 02664-1120 TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ NO❑ FIXTURFS ; 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❑ 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'V298 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE August 16,2021 PERMIT# BLDP-22-000867 JOBSITE ADDRESS 668 ROUTE 28 OWNER'S NAME MANNING GERALD TR G OWNER ADDRESS THE PARKER RIVER REALTY TRUST 121 MAYFLOWER TERR SOUTH YARMOUTH TEL MA 02664-1120 TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 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 0 JP❑ JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# 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 GAS FITTING WORK _',r'_ 2 - $cal `tGh CITY [WEST YARMOUTH MA DATE L 0812/2021 PERMIT# JOBSITE ADDRESS 668 MAIN STREET OWNER'S NAME GERALD MANNING/CAPTAIN PARKERS GOWNER ADDRESS [SAME 1 TE 508.771.4266 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL I 1 RESIDENTIAL PRINT CLEARLY NEW:[J RENOVATION:, REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO Li APPLIANCES Z FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER li ' 1' I I at - 'Nig mai in, . :•• BURNERONVERSION miliisaa im___ _____ __ _____ ___ , COOK STOVE ama . ___ __ 1 w DIRECT - __ ami-- . DRYER Mg 1- lei , _. FRYOLATOR IIIIIMFIESIMUNK. MM1MannaM _1:11 11111111.011M I l LABORATORY COCKS 1 - fila 1 -. OVEN 10111W11.1 POOL HEATER --MWSKIK 1 _ in _ um __ aliti _ at _ , ROOM/SPACE HEATER imp mm mi mi. _ .. ROOF TOP UNIT MIN MN.l TEST iiiiiimitait sum.not siiiiiiiimaiiii.am amoistiiiim UNIT HEATER 'iiiii _ OM'11.111M1.011.1 UNVENTED ROOM HEATER 1111110MMINICIMilligligralUNIIIIMMINIalialliall OTHER mw mug aim I� 1 1 CIA t .. �Il.'�'i + INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 11 1 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L OTHER TYPE INDEMNITY Li BOND Li 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 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 ajYP rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws 71 • `/ PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE#j 12298 SIGNATURE MP MGF JP 0 JGF 0 LPG'j CORPORATION 0# 3281C PARTNERSHIP S# ---]LLC 0# .. COMPANY NAME:1 E.F.WINSLOW PLUMBING&HEATING i ADDRESS i 8 REARDON CIRCLE CITY SOUTH YARMOUTH j STATE MA ZIP 1 02664 TEL 508-394-7778 FAX 1-508 394 8256 ;CELL N/A IEMAILFINSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts ' Department of Industrial Accidents _ =9Office of Investigations ; l'' � + � Lafayette Ci Center �44= 2Avenue de Lafayette, Boston,MA 02111-1750 w — . 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 pal mime).* — 6. ❑ 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. [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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ 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 • el'the ins and penalties of perjury that the information provided above is true and correct. (" f/ / 01/02/2021 Signature: ` Y — .....'J''-'' 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): 1I:Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK f CITY WEST YARMOUTH MA DATE PERMIT# 2Z — 8(o-1 u.., JOBSITE ADDRESS 668 MAIN STREET OWNER'S NAME GERALD MANNING/CAPTAIN PARKERS POWNER ADDRESS SAME _ TEL 508.771.4266 FAX , TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:LI RENOVATION:® REPLACEMENT:L PLANS SUBMITTED: YES NO® FIXTURES 1 FLOOR BSM 1 2 I 3 4 5 I 6 j 7 1 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE i DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM L DEDICATED GREASE SYSTEM OM DEDICATED GRAY WATER SYSTEM j DEDICATED WATER RECYCLE SYSTEM DISHWASHER ,i DRINKING FOUNTAIN FOOD DISPOSER . , FLOOR/AREA DRAIN ... INTERCEPTOR(INTERIOR) �, , ' KITCHEN SINK LAVATORY ROOF DRAIN 1 � I SHOWER STALL ( . I SERVICE/MOP SINK TOILET URINAL ; i 1 — WASHING MACHINE CONNECTION I ! WATER HEATER ALL TYPES 1 WATER .,,, 1 1 , al OTHE R PIPING I-I�. ..' ,„,„ _ 1 . - ,w, .:� _. _ _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES J 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 ® 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 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 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 Ii with II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r '". 4,...,- PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP Lj JPLJ CORPORATION Li# 3281C PARTNERSHIPLJ# 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 l v/G , /r 6,..,1-, Ag /gdey, ,0 (/),,7,41,0 k7JZA7 -ems The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations �L '' =�— Lafayette City Center J = < 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. 0 Retail or part-time).-* 6. D 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. [No workers'comp. insurance required] 8. 0 Non-profit 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]** 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 *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 • er the ins/and penalties of perjury that the information provided above is true and correct. Signature: Y,,ff/• `� 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 30 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia