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HomeMy WebLinkAboutBLDP-23-000402 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK „',• w, E, CITY 'YARMOUTH MA DATE 7/26122 PERMIT# BLDP-23-000402 M- JOBSITE ADDRESS 7 RITA AVE OWNERS NAME MANN PHILIP G OWNER ADDRESS MANN JUDITH E 7 RITA AVE SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:m 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❑ OWNERS 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 12298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME !STEPHEN A WINSLOW ADDRESS 18 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE IMA ZIP 026641207 TEL FAX CELL I EMAIL inspections@efwinslow.com K8AGSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �� CITY ___'______' 3MA DATE _ 8PE�N|T# ~°'— JO8S|TEADDRESS 7R|TA AVE SOUTH YARMOUTH ! OWNER'S NAME JUDITHMANN__________________~ �— OVNERADDRESS _7_R_]T_A_-AVE_SOUTH Y_AR_MOU_H__ TEL-==��=��_ _ ,FAX_ TYPE | ��F� OCCUpANCYTYPE C0��ERC|ALF—1 EDUCATIONAL �l RES|DENT|ALM pFK|NT NEW:�� RENOyAT|ON��l REPLACEMENT: PLANS YES NO�� CLE��F�[� �`` ��� �.__. � �� ._° FIXTURES-1 FLOOR- eSm 1 2 3 4 S 0 7 8 8 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM "A DEDICATED GAS/OIL/SAND SYSTEM ------- DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM M MOW DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) __t,__Aj KITCHEN SINK LAVATORY ROOF DRAIN TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER liw4RANCE COVERAGE: I have a current liabilitv 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 P0L|CYF.] OTHER TYPE OFINDEMNITY 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 EJ AGENT [:_1 ~^ SIGNATURE OF OWNER 0RAGENT /hereby certify that all of the details and information|have submitted or entered moo�ino this application m u* and that all plumbing work and installations performed under the ponnx ioovox for this application will be in cornpli wit 11 ertine9fproyisior),ofthe o Massachusetts State apmmxinoCode and o»o� m*r�4zmouononu/Lawm. - �u0 PLUMBER'S NAME STEPHENVV|NSLOW LICENSE#| 12298 | SIGNATURE w� ^� —^ MpE] JP�� CORPORATION 3281C |PARTNERSH|P���_ _A��| �# ~ COMPANY NAME E.F.VNNSLOVV PLUMBING&HEATING ADDRESS 8REARDONCIRCLE CITY| SOUTH YARMOUTH |STATE MA ZIP |02664 | TEL|6O8�O4�778 | / | FAX|5O8-394-825G | CELL| N6A | EMAIL \ |NSPECT|ON NSL0W.00M \ _ ` ~ The Commonwealth of Massachusetts w Department of Industrial Accidents . ,,, =a1'9 —`ti _ Office of Investigations = 3ti �� Lafayette City Center =.. was ;f 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.W I am a employer with 90 employees (full and/_ 5. ❑Retail 2.❑ or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 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 no employees. ** 10.❑Manufacturing [No workers' comp. insurance required] 4.ElWe are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *My 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 01/01/2022 Expiration Date: 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: %y L (/,,,.4 . 01/02/2021 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 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK : CITY IYARMOUTH I MA DATE July 26,2022 PERMIT# BLDP-23-000402 JOBSITE ADDRESS 17 RITA AVE OWNER'S NAME MANN PHILIP G G OWNER ADDRESS MANN JUDITH E 7 RITA AVE SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES ❑ NO❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 _BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY El 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-GASFITTER NAME 'Stephen Winslow 'LICENSE# 112298 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑#I I PARTNERSHIP ❑#I ILLC ❑# COMPANY NAME: ISTEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH 'STATE (MA I ZIP 1026641207 I TEL I FAX 1 1 CELL 1 1 EMAIL Iinspections(oaefwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK y — ramA Tit 41 CITY ,YARMOUTH m ,,_ _ _ _ --I MA DATE 7/20/22 _ ¢ _ 2, PERMIT# 2-3— °`167-- JOBSITE ADDRESS 7 RITA AVE SOUTH YARMOUTH 1 OWNER'S NAME I JUDITH MANN GOWNER ADDRESS I 7 RITA AVE SOUTH YARMOUTH _ TEL5083984317 FAX , TPRINT PE OR OCCUPANCY TYPE COMMERCIAL, EDUCATIONAL r RESIDENTIAL CLEARLY NEW:I—I RENOVATION:Li REPLACEMENT:rd PLANS SUBMITTED: YES CA NO I APPLIANCES 1 FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER 1 1 1 . I I, FIREPLACE ' I {r FRYOLATOR (� r--- L i iL t :u E ' : FURNACE I--,._._,LW.._ IL w,,II _ JII .At I GENERATOR GRILLE . INFRARED HEATER . ', . .. , w.` r LABORATORY COCKS MAKEUP AIR UNIT r i ,. .. OVEN I J I POOL HEATER ROOM/SPACE HEATER I,--,_.. _,_ IT—IF ..t I t , ROOF TOP UNIT , .,,. __, I ._,_ _ I - _I___ - � TEST : ,. UNIT HEATER m - � � UNVENTED ROOM HEATER ��r _ - J . . _. _i a WATER HEATER ! mum am ow imm immii nil OTHER �_..._ " INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1'1 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ;„•',A OTHER TYPE INDEMNITY BOND ba 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 1„,, I AGENT El 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 accurat to the st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian al!'Pertine provision f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � 71/1 —' ..... PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP MGF 1 JP I_._. JGF r LPG'I CORPORATION(, ,# 3281C m ,,, PARTNERSHIP I,,.„.# ym LLC # • :n COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY I SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 1 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM— , , The Commonwealth of Massachusetts a Department of Industrial Accidents =�`� f Office of Investigations = 1= Lafayette City Center } mar—ji,i 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): I.❑■ I am a employer with 90 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. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *My 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:01/01/2022 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 a the ins and penalties of perjury that the information provided above is true and correct. ( f-. .�.•oh-, 01/02/2021 , 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): 1.❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia