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Home My WebLink AboutBLDP-22-006945 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ri CITY YARMOUTH MA DATE 6/1/22 PERMIT# BLDP-22-006945 '- - JOBSITE ADDRESS 66 MAYFLOWER TERR OWNER'S NAME Chris Speers P OWNER ADDRESS 66 MAYFLOWER TER SOUTH YARMOUTH,MA 02664-1117 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑ FIXTURFS FLOORS--0 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 El 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 LICENS412298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com . , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _.:%ice 4 -Z Z `t .. -, CITY YARMOUTH MA DATE 5/24/22 PERMIT# JOBSITE ADDRESS 66 MAYFLOWER TERRACE S YARMOUTH OWNER'S NAME CHRIS SPEERS 1 GOWNER ADDRESS 651 EAST 14TH ST SPT 3-D NEW YORK NY 10009 TEL TEL 5083988739_ IFAX . _' TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 11 RESIDENTIAL ra PRINT CLEARLY NEW: , RENOVATION:0 REPLACEMENT:Lfj PLANS SUBMITTED: YES D NOD APPLIANCES 7 FLOORS—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER 3i CONVERSION BURNER COOK STOVE iiiriliiiiiiiiiiiirmiiiirlimirwilirMilliwaiirimarmit DIRECT VENT HEATER DRYER WIIIIIWWWWWWW ;, FIREPLACE FRYOLATOR FURNACE , F _ 1 INFRARED HEATER MI_MBIRRAWAIII,M.Int lialltrIK MIR IIIIII NW LABORATORY COCKS MAKEUP AIR UNIT , OVEN 1 ,--1111111R111111 am___ r"---- I POOL HEATER i ROOM/SPACE HEATER ROOF TOP UNIT TEST I_ WNW,,,,, I _ 111111EW 1 _ _ !IR _ UNIT HEATER 1 UNVENTED ROOM HEATER I 1 . WATER HEATER 1 OTHER. - 1111111111111,NM MI MI _ ,MI 111.111111111 MIN Mt Mt MN MI , '!IwL _,. ,ow rigiritrini INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 121 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Li OTHER TYPE INDEMNITY Li 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 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 b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian a P�rtine provision of the vs. Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �i !/� -. o PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE J ° MP ° MGF JP JGF LPGI® CORPORATION # 3281C PARTNERSHIPLJ# LLC D# N '-- COMPANY NAME:[E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE (P. vt CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 1 FAX 508-394-8256 CELL NIA EMAIL INSPECTIONS@EFWINSLOW.COM f 1 The Commonwealth of Massachusetts Department of Industrial Accidents � Office of Investigations c =+�1= Lafayette City Center _� r 2 Avenue de Lafayette, Boston,MA 02111-1750 °- ^M � 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 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 • the ins and penalties of perjury that the information provided above is true and correct. Signature: Date: 01/02/2021 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 2.1=1 Building Department 3.1=1 City/Town Clerk 4.0Licensing Board 5.12 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia