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HomeMy WebLinkAboutBLDP-23-004205 , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • CITY YARMOUTH MA DATE 1/30/23 PERMIT# BLDP-23-004205 JOBSITE ADDRESS 13 CARTER RD OWNER'S NAME Mark Fallon p OWNER ADDRESS 13 CARTER RD SOUTH YARMOUTH,MA 02664-4405 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© 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 0 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❑ 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#2298 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 �wn. N. 5.— �%=v„ CITY Yarmouth MA DATE 1/26/23 PERMIT#23 — L. 2 v } ssk'� JOBSITE ADDRESS 13 Carter Road I OWNER'S NAME Mark Fallon POWNER ADDRESS same I TEL 781-710-4281 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL El PRINT CLEARLY NEW:® RENOVATION:® REPLACEMENT:0 PLANS SUBMITTED: YES® NOD FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB � i CROSS CONNECTION DEVICE NM iiii NMI 11111111 MI ail MN 1111111R, DEDICATED SPECIAL WASTE SYSTEM 1 ( J DEDICATED GAS/OIL/SAND SYSTEM - _ DEDICATED GREASE SYSTEM NIB innan 1111111111.0111111 MN MI NE NM MI aii MI��:11111 DEDICATED GRAY WATER SYSTEM �1 nuiraffwilimurraitiorsorimiamwmur DEDICATED WATER RECYCLE SYSTEM WIIIIIIFIIIIIIFWIINIIIMIFSIIIHIOIIIIFWIIIIIISIIIFSIIIIIFIIIIIJIIIIIFIIIIIIIIIIN DISHWASHER i 111111DRINKING FOUNT ' FOODIIIIII DISPOSER AIN � d FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) 1111111111111111111111111111111111111111.1111.110111.11111111111111111.111111111.111111111 KITCHEN SINK LAVATORY E € i ROOF DRAIN an SIM 1111101 NM Mill Mil MN III.MR MIN ME MN IIIIII gni Ns SHOWER STALL 1I 1I , 111. III llInallitnliallIM6INZIRMS RI011 TOILET URINAL 1 a RRRRRRRRRRRRRRR mg WASHING MACHINE CONNECTION 1I _�� WATER HEATER ALL TYPES am� 1 i WATER PIPING •THE' -. .... .. _........... ..... n Rwn _.._1 i. nienn 11111111111111111111111111111111111111111111111111111111W11111111111111111111t111.11111111111111111111111111.11111111111111111111111111111111111111 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITY 0 BOND Q 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 0 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 li wit II ertine proxisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -.,. ..+.�s..�- PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MPQ JP® CORPORATIONQ# 3281C PARTNERSHIP0# LLCQ# 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 i EMAIL INSPECTIONS EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents z .-- , _ _ Office of Investigations Lafayette City Center =" = % 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): 1.0 I am a employer with 99 employees (full and/ 5• 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, MO 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: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 ' 7 the ins and penalties of perjuty that the information provided above is true and correct. Signature: 4,-.-- 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 4.0Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia