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Home My WebLink AboutBLDP-23-005676 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK z CITY YARMOUTH MA DATE 4/11/23 PERMIT# BLDP-23-005676 JOBSITE ADDRESS 40 BUCKWOOD DR OWNER'S NAME WEBB DANIEL J P OWNER ADDRESS C/O DANIEL J WEBB 40 BUCKWOOD DR SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURES z FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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 0 NO 0 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 12298 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 m_tkl 4 CITY YARMOUTH I MA DATE 4/11/23 PERMIT#ils. --CI �� SL JOBSITE ADDRESS 40 BUCKWOOD DRIVE OWNER'S NAME ASHLEY MAHLER P OWNER ADDRESS SAME TEL 774-208-3254 JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL ED EDUCATIONAL ED RESIDENTIAL LI PRINT CLEARLY NEW:Ej RENOVATION:0 REPLACEMENT:Ej PLANS SUBMITTED: YES 0 NO0 FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM mourimiromiliniaminurwomiwintimiliorimmursei DEDICATED GAS/OIL/SAND SYSTEM WIIKEWIWIIM. IMMIIIIMIWEIr MI WI. DEDICATED GREASE SYSTEM � � it i DEDICATED GRAY WATER SYSTEM i � DEDICATED WATER RECYCLE SYSTEM 1 i 1_._ . . I. .. .I DISHWASHER DRINKING FOUNTAIN �W. _.rv_.e, ,� _ __.. _ )I�. 11.. �I `. FOOD DISPOSER I , , FLOOR/AREA DRAIN 1 � I Ii. i INTERCEPTOR(INTERIOR intinutmisinnutimimormanimaiiiiiiiiirmerillillill KITCHEN SINK LAVATORY awl incamormumerainsinumitimomill.11.11111Willir ROOF DRAIN ' SHOWER STALL �� 11111,111111111111111111111111.1111111111.111111111 SERVICE/MOP SINK IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIWINIIIIIIIIIIIIIIIMMINFIN. TOILET llllll MR IMO MIMI OMNI NM Jail 1111111 MEI 11111111 URINAL 1_ m WASHING MACHINE CONNECTION I WillitiMaillill. WATER HEATER ALL TYPES 1 WATER PIPING �..�.m� . _A.:. __ OTHER _ I Imummaiouromirmoriuminetworarinrwourwaimrsormani sanammumiammumuriurimEmslormwomisoriailwwimorommiimit INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ri. NO E 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 Ej 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 El 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 wit ll ertine proyisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. !/ PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 ..�.A�� .SIGNATURE MP 0 JP0 CORPORATION ED# 3281C PARTNERSHIP( # Lc 0# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE y CITY SOUTH YARMOUTH I STATE L MA 1 ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents -- ►'�y Office of Investigations =? _oil Lafayette City Center A,.ems — g — _ 2 Avenue de Lafayette,Boston, MA 02111-1750 ` 'e''' 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 120 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 3.0 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]** 4.0 We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.❑ 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 cer ' e1 the ins and penalties of perjury that the information provided above is true and correct. Signature: 11 ...pi. 01/01/2023 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): 1°Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia