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HomeMy WebLinkAboutBLDP-23-003876 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 1/17/23 PERMIT# BLDP-23-003876 JOBSITE ADDRESS 16 SPINNING BROOK RD OWNER'S NAME BADACH AMY E P OWNER ADDRESS 16 SPINNING BROOK RD SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES NO❑ FIXTURES z 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❑ 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. PLUMBERS NAME Stephen Winslow LICENSE W298 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 -- '�= CITY Yarmouth `1(i_ MA DATE 1/10/23 I PERMIT# 23 " 3 2 . JOBSITE ADDRESS 16 Spinning Brook Road I OWNER'S NAME Amy Badach P OWNER ADDRESS same I TEL 508-394-4618 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ® RESIDENTIAL El PRINT CLEARLY NEW:® RENOVATION:El REPLACEMENT:1j PLANS SUBMITTED: YES NOD FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB i ii 1 u 1 1 ,� IF --- I l � -• • • • DEDICATED • , DEDICATED GRAY WATER SYSTEM 1 ' 1 _ l' ; I, I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DINFOOI1t*r 11 _a r I I , li p FLOOR/AREA DRAIN imrsoirmramunimannemnmerminniaminarwm INTERCEPTOR(INTERIOR) KITCHEN SINK111111111.1111111111111111111 i i l LAVATORY ROOF DRAIN X SHOWER STALL Mt 1111.1111111111.1111111MIIIIIIIMINIMMINFINIFINIMIFION SERVICE/MOP SINK milis TOILET wriumunton om. URINAL WASHING MACHINE CONNECTION 1.11111111111111111_ ��� WATER HEATER ALL TYPES '` „ � —� '� WATER PIPING �.. OTHER wow NW 11111111111111111 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 — ` :Tam-aware-that the-licensee-does-not havvethe.insurance coverage Massachusetts General Laws,and that my signature on this permit application waives this requirmentquedby-Chapter 142 of the SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER El AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and-scour a 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 wit II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME J STEPHEN WINSLOW LICENSE# !!12298 Y SIGNATURE t MP LI JP® CORPORATION El#L3281C JPARTNERSHIPEl# LLC0# COMPANY NAME l E.F.WINSLOW PLUMBING&HEATING I ADDRESS�8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA I ZIP 02664 TEL 508-394-7778 I FAX I508-394-8256 l CELL LN/A I EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents __ Office of Investigations ... i 1 ,, Lafayette City Center I' t 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 99 employees (full and/ 5• 0 Retail 2.0 or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 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 no employees. ** 10.❑Manufacturing [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: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 ' e the ins and penalties of perjury that the information provided above is true and correct. Signature: L` ,..�1...�- 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 3.0 City/Town Clerk 4.OLicensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia