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Home My WebLink AboutBLDP-23-004041 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK pk= , CITY YARMOUTH MA DATE 1/23/23 PERMIT# BLDP-23-004041 • -,I JOBSITE ADDRESS 237 STATION AVE OWNER'S NAME Bass River Pediatrics P OWNER ADDRESS 237 STATION AVE SOUTH YARMOUTH,MA 02664-1863 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL ❑ 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 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND 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 WATER PIPING 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 El NO ❑ 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. PLUMBER'S NAME Stephen Winslow LICENSE 12298 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 i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -w At ='awn w-- ' Z3 — 4'OLt/ 1=y CITY Yarmouth I MA DATE 1/16/23 'PERMIT# JOBSITE ADDRESS 237 Station Avenue 1 OWNER'S NAME Bass River Pediatrics 1 POWNER ADDRESS same I TEL 508-394-2116 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Ej PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:ID PLANS SUBMITTED: YES 0 NO FIXTURES-I FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 1i 1 1 CROSS CONNECTION DEVICE IOW MI r DEDICATED SPECIAL A SD SYSTEM � 111111111111 � �111111111.11111111111111111111111111111111111111111. �I�� DEDICATED SPECIAL WASTE SYSTEM � f DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM 11111111111111111111111111111111111111111.111111111111111111111111111111111111.11, DEDICATED WATER RECYCLE SYSTEM glimirigr amiggrigrigniwimigurigurogrogrouguidi _ MINN DRINKING FOUNTAIN � � f FLOOR/AREA DRAIN 1 FOOD DISPOSER INTERCEPTOR(INTERIOR) 11111111111.1111.111111111111111111111111111.11111111111.11111111111.1111111111111111111111 KITCHEN SINK IIIIIFIIIIIFIMIIFIIIIFIIIMIIIIIIIIIIIIFIIIMIFIIIIIIFIMIIFIIIIFIIIIIIIIIIWMIIWIIIM LAVATORY I L . i ROOF DRAIN11111111111.1111111111111.11111111111111111111111111111111.011111111 NM SHOWER STALL 11.111111111111111W1111011111IMW11.111111011111011WOMICIIIIMIJ SERVICE I MOP SINK 111111,111111-11111111111110111111111111111111111111.511,1111111W111111111111111111111111111111111 TOILET MIR IIIIIIMI Mit MIMI INN MOM MIMI 111111111111111111111111 URINAL WASHING MACHINE CONNECTION 1 I mT ! 11111.1 WATER HEATER ALL TYPES - p INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO L p Y IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEM_NILY BOND La 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 a to the 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. PLUMBER'S NAME STEPHEN WINSLOW J LICENSE# 12298 1 SIGNATURE MPQ JP O CORPORATION( # 3281C PARTNERSHIP®# LLC®# I COMPANY NAME E.F.WINSLOW PLUMBING&HEATING , ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH 1 STATE MA 1 ZIP 02664 1 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONSta EFWINSLOW.COM The Commonwealth of Massachusetts .� { Department of Industrial Accidents Office of Investigations =- 1= Lafayette ette 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. 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. ❑ 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 *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 e the ins and penalties of perjury that the information provided above is true and correct. Signature: 1' ,-. ,...�......- 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): 1CBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia