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HomeMy WebLinkAboutBLDP-23-004067 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _,�_� CITY YARMOUTH MA DATE 1/24123 PERMIT# BLDP-23-004067 11 JOBSITE ADDRESS 82 SIERRA WAY OWNER'S NAME EBREO MICHAEL A P OWNER ADDRESS EBREO CAROL A 82 SIERRA WAY WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL E PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 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. 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 0 JP 0 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 ir :�ia- CITY Yarmouth J MA DATE 1/13/23 PERMIT# z3 v 4O0 JOBSITE ADDRESS 82 Sierra Way I OWNER'S NAME Michael Ebreo I POWNER ADDRESS same I TEL 508-694-7864 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ID RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:O PLANS SUBMITTED: YES 0 NO LI FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB , 1 I I 1 i CROSS CONNECTION DEVICE F DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/01USAND SYSTEM ingmerwsurimmiraiwairinerwomrsiguerour DEDICATED GRAY WATER SYSTEM 1 __ iDEDICATED GREASE SYSTEM _ 1 . , DEDICATED . . .ECYCLE SYSTEM _ 1 �I ,_ I111111, - _ DISHWASHER �I a*aa**R* IU . f DRINKING FOUNTAIN I I I' f lf_, —T FLOOR/AEA DIN '. i N ERC PTOR(INTERIOR) 1 1 - 1 I• � I 11111111M KITCHEN SINK LAVATORY lilt wwwwwwirimirintiiiriguriminutimmi ROOF DRAIN an 0111111111111 NM NM 11111 NM MOO 01111,11111 MOO NOM NON NM all SHOWER STALL i 1l 1 11111 % TOILETSERVICE/MOP SINK MEM INCi_ -_ I URINAL111.111111.111111111111111111111.11111111111111.11111111.1111111.111111111111.11111111111111111111111 WATERIIIIIIFIIIIIFIIIII HEATER ALL ONNS Q I :.. I l�1 WASHING MACHINE CONNECTION WATER PIPING OTHER I IkjIIILIMIIIIIIIIIIIIIIIIMIIIIIIIIIIIIIIIIIIIIIIIMIII-MO MAM 1101 INN MN MR I� -INN l INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 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 0 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 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 Ir�p i- , with II ertine proXisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i "+ ,w.v PLUMBER'S NAME STEPHEN WINSLOW :LICENSE#112298 I SIGNATURE MPO JPO CORPORATION 0# 3281C PARTNERSHIP ID# LLCL# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ` ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 I FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS©EFWINSLOW.COM The Commonwealth of Massachusetts _ , fl Department of Industrial Accidents R. =1= Office of Investigations I == = .f y City ette La a Center "'®firli 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): LIE I am a employer with 99 employees (full and/ 5. 0 Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.0 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: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 ' el'the ins and penalties of perjury that the information provided above is true and correct. Signature: 1' ' lam--- 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 2.1:1 Building Department 30 City/Town Clerk 4.1:Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia