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HomeMy WebLinkAboutBLDP-22-006936 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 6/1/22 PERMIT# BLDP-22-006936 • r L JOBSITE ADDRESS 62 RAYMOND AVE OWNER'S NAME VERNAVA ROBERT M JR TR OWNER ADDRESS ITHE RAYMOND AVE TRUST 73 PROSPECT ST SWAMPSCOTT,MA 01907 TEL P TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:at PLANS SUBMITTED: YES❑ NO❑ FIXTURES 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 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 I LICENSE'12298 I SIGNATURE MP JP CORPORATION El# PARTNERSHIP ❑# I I LLC ❑# I I © ❑ • COMPANY NAME ISTEPHEN A WINSLOW ADDRESS 18 REARDON CIR 8 REARDON CIR CITY IS YARMOUTH I STATE IMA I ZIP 1026641207 I TEL I FAX I I CELL I I EMAIL (inspections@efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY SOUTH YARMOUTH MA DATE 5/20/22 _�PERMIT# • JOBSITE ADDRESS 62 RAYMOND AVENUE 1 OWNER'S NAME ROBERT VERNAVA 14 P OWNER ADDRESS SAME TEL 781-254-1415 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ID EDUCATIONAL D RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:Ei REPLACEMENT:Li PLANS SUBMITTED: YES LI NO FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 I 10 11 12 13 14 BATHTUB ! DEDIcATED s IN EpaaraCI-BFMgllmgppppmIIIIIIIIIINIIIIIJIINI MI IIINI NNIIIINIIIMIINIINIIIIIMNIIII DISHWASHER M 11111 I Nal NM N pot MINIM NIS NIIIIIIII .._ . DRINKING FOUNTAIN INIPHIN1 MN=IIIIIIIIIN MI NI INFI — — FLOORFOOD DISPOSER MIN IIIIIIMIN AO i pop imp ppm= DRAIN KITCHEN SINK ME iii M.pm Ns am iiINIIIIII IIIIINIIIII NE ROOF DRAIN NMI NM IIIININI SHOWER STALL SERVICE/MOP SINK TOILET URINAL — _ 41111111'MUM � WASHING MACHINE CONNECTION WATER HEATER ALL TYPES Wil IIIII INII NIII INII OM WATER PIPING OTHER IIIIIIIIIIIII MIIM MO MI III III Nis pinNiMNIIMINIIIIIIIII NW MUNN W 01111111M 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 0 OTHER TYPE OF INDEMNITY D 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. CHECK ONE ONLY: OWNER El 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 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 .LICENSE# 12298 SIGNATURE MP Ej JP LI CORPORATION Ej# 3281C PARTNERSHIP El# LLC # COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH 1 STATE MA ZIP 02664 TEL 508-394-7778 FAX 508 394 8256 1 CELL NIA 1 EMAIL INSPECTIONSaI EFWINSLOW.COM N 1 The Commonwealth of Massachusetts Department of Industrial Accidents • l i r Office of Investigations Lafayette City Center nay a 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 99 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.❑ 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]** 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 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: City/State/Zip: Policy#or Self-ins. Lic.#1964A Expiration Date:01/01/2023 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 the ins and penalties of perjury that the information provided above is true and correct. Signature: T "` _ .. .L- Date: 12/01/2021 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 20 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia