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HomeMy WebLinkAboutBLDP-23-005960 —,. -. f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK . �a�f� CITY YARMOUTH PORT MA DATE 4/25/23 1 PERMIT# JOBSITE ADDRESS 109 NOTTINGHAM DRIVE J OWNER'S NAME[ TEVEN GRAZIANO P OWNER ADDRESS SAME TEL 617-905-0002 ,FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL [j RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:E3 REPLACEMENT:0 PLANS SUBMITTED: YES El NOEJ FIXTURES 1. FLOOR-* BSM 1 2 3 4 5 6 7 18 9 10 11 12 13 14 BATHTUB 1 dl d.. CROSS CONNECTION DEVICE 1 1 I , f DEDICATED SPECIAL WASTE SYSTEM it DEDICATED GAS/OIL/SAND SYSTEM Jourimialitimawmairaurimrsoineursorwsuraur DEDICATED GREASE SYSTEM IIII al IIII MIN IIINININNIIIIIIIIIIINIMIIIIIIIIIIIIIIIII INK DEDICATED GRAY WATER SYSTEM 111111111mimaiiniurawant IIIIIIIIIIIIIIIIEW1111.1111111111.111111DEDICATED WATER RECYCLE SYSTEM ,_,_ ,_ , i , it _, , „ FOUNTAINDRINKING FOOD DISPOSER I I - I , 111111111.111111 FLOOR/AREA DRAIN 1111111111IIIIIIII1M1111111111111111111111111111111111111111111111111 INTERCEPTOR(INTERIOR KITCHEN SINK 1.11011.11tM11111.111•11111111111111111111111111111111111111111111111111111111111111111.111111111.11r LAVATORY , Di ,, . ‘, .. n z ROOF DRAIN song I , SHOWER STALL umimmmorsuir.rommeriamormiumilwinirnunir SERVICE/MOP SINK TOILET URINAL RR , , WASHING MACHINE CONNECTION WATER HEATER ALL TYPES i_ WATER PIPING OTHER I�._ m. I1.111111101111111111 ` i IIMINIMMINIMINFINIIIIIIIMIIMMIFINI1 s INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ej NO Ej IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITY pi 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 123 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 to 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 II ertine proyisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. !/ PLUMBER'S NAME STEPHEN WINSLOW r G. �"� LICENSE# 12298 SIGNATURE MP JP© CORPORATION #L3281C q PARTNERSHIPQ# LLCp# COMPANY NAME! E.F.WINSLOW PLUMBING&HEATING j ADDRESS 8 REARDON CIRCLE CITYf SOUTH YARMOUTH STATE L MA ZIP 02664 j TEL 508-394-7778 FAX 508-394-8256 J CELL N/A EMAIL LINSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts , . -- Department of Industrial Accidents _.._ f, R. = 1= Office of Investigations , `f Lafayette City Center p ?=z, 2 Avenue de Lafayette, Boston,MA 02111-1750 a too'',. 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 requn di 8. El Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainrrr t their right of exemption per c. 152, §1(4),and we have 10.❑ Manufact .__.6 no employees. [No workers' comp. insurance required]** 11.0Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 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 ' er the ins and penalties of perjury that the information provided above is true and correct. f/ 01/01/2023 Signature: Y "' 'X.-- 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 2.1=1 Building Department 30 City/Town Clerk 4.1:Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia