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Home My WebLink AboutBLDP-23-005204 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH‘44.:,, ,,, MA DATE 3/22123 PERMIT# BLDP 23 005204 ' JOBSITE ADDRESS 47 CHERRY LN OWNER'S NAME RY-ANN DUMAURIER P OWNER ADDRESS 47 CHERRY LN WEST YARMOUTH 02673-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:. YES NO 0 FIXTURES 4 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 1 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 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 0 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 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 f2298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 TEL 5083947778 FAX CELL EMAIL inspections@efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -;si=M -"Z 3 UbSoD 1i= h CITY Yarmouth MA DATE 3/15/23 PERMIT# JOBSITE ADDRESS 47 Cherry Lane I OWNER'S NAME Ry Ann Dumaurier P OWNER ADDRESS same I TEL 774-722-1866 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL [2 RESIDENTIAL D PRINT CLEARLY NEW:El RENOVATION:® REPLACEMENT:0 PLANS SUBMITTED: YES El NOQ FIXTURES 7 FLOOR-i BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE NMI MIMI MIK MN IMII NM NMI MI MI MI In NMI NM MI NMI DEDICATED SPECIAL WASTE SYSTEM 111111111.1111111111111111111111111111.111111111.1111.1.111111.1.11IINFNIIIIII DEDICATED GAS/01USAND SYSTEM ; DEDICATED GREASE SYSTEM No am imp INN IM IIMIIIII MI MI MI IIIII IIIIIIIII NMI 1�1 �I IE DEDICATED GRAY WATER SYSTEM WI illIllrilirillIllFW1MllrIMIFIMIIFWIIIIIIIIIrllIll 111111111111.117 Mt DEDICATED WATER RECYCLE SYSTEM 11.111,11111.il win Immagurior 'i In — DISHWASHER MMIENIIIIIIIIII1IINI- DRINKING FOUNTAIN 11111101111wismiumwourourimiromFmmoriNgommur �� FLOOR/AREA DRAIN r ��I FOOD DISPOSER �(� � � � �I INTERCEPTOR(INTERIOR) dirwairintint KITCHEN SINK anrimitouraniumi ma ow , LAVATORY ROOF DRAIN al.INK IIIIII MI M.gni MI IMIM MI MI NU NM In MINI MI' _ - i SHOWER STALL � _ ' SERVICE/MOP SINK IIIIIIIIIIIIIIIIIIIIIIIIIIIIINFINIFINNEWINIFFINIMIIIIIII TOILET 1-_ i URINAL , 1 ,, , • WASHING MACHINE CONNECTION �—_. RRIE , MR f :_-- ---___._!__ WATER HEATER ALL TYPES MOM In 11.115 an MB,all 111111111 WATER PIPING I '�IIIII, OTHER 1111111111•11111111111111111111111111111111111111.11111111111111.11...111111,11111111111111111111111 111111111111111111111111111111111111111111 11111111.11.1111111111111111 Inn NM NM Ali MI MI AN NE NM MI IMIN linamanniimmummill11111winig ninoriminorwwwilwaltimiwillill INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO Li IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY-El OTHER TYPE OF INDEMNITY 0 BOND Lj 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 a to the 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 proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (�\, ....., .w.p I.r^ PLUMBER'S NAME STEPHEN WINSLOW I LICENSE# 12298 SIGNATURE MP JP® CORPORATIONQ# 3281C PARTNERSHIP®# LLC0# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 1 TEL 508-$9 7 C E I V E..p FAX 508-394-8256 : CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM MAR 2 01023 BUILDING DEPARTMENT The Commonwealth of Massachusetts • Department of Industrial Accidents M 1- Office of Investigations Lafayette City Center 2 Avenue de Lafayette,Boston, MA 02111-1750 t' 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): LP I am a employer with 99 employees (full and/ 5. ❑Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.D 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0Health 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:23 Commonwealth Avenue City/State/Zip: Chestnut Hill, MA 02467 Policy#or Self-ins. Lic. #2019A Expiration Date:01/01/2024 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 er the ins and penalties of perjury that the information provided above is true and correct. 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): 10Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other 4,04 Contact Person: Phone#: www.mass.gov/dia