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HomeMy WebLinkAboutBLDP-23-003124 l MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 47 CITY YARMOUTH MA DATE 12/6/22 PERMIT# BLDP-23-003124 U" JOBSITE ADDRESS 42 RIVER ST OWNER'S NAME Deb heneghan OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© 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 1 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 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❑ 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 ❑# I I PARTNERSHIP ❑# I I LLC ❑# I i ❑ ❑ COMPANY NAME ISTEPHEN A WINSLOW I ADDRESS 18 REARDON CIR 8 REARDON CIR CITY IS YARMOUTH I STATE IMA ZIP 102664 TEL 15083947778 FAX I I CELL I EMAIL (inspections@efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK "k( CITY YARMOUTH MA DATE 12/5/22 —1PERMIT# •L3- 3/247 -_4 JOBSITE ADDRESS 42 RIVER STREET OWNER'S NAMEEB HEVEGHAN POWNER ADDRESS!SAME TEL 860-402-3a95 -- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL LI EDUCATIONAL Ej RESIDENTIAL El PRINT CLEARLY NEW:0 RENOVATION:D REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOQ FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB llotaMMOMIIIIENIKSIS " CROSS CONNECTION DEVICE 1 = 11111 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM z �" DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN . .a_r- -t=rs� w` »q: 'Li 1 , I. +w a ',Z.—� I t.L. F000 DISPOSER I FLOOR/AREA DRAIN ..: . _..- , .. mow, INTERCEPTOR INTERIOR KITCHEN SINK _ o _ LAVATORY ROOF DRAIN ., t �i :. 1 � SHOWER STALL ,i SERVICE/MOP SINK ,� TOILET . t � � f rimi SW �'��; URINAL »s !OM �x x a a®+w MN OW AM WASHING MACHINE CONNECTION WATER HEATER ALL TYPES i . ° � �* e WATER PIPING t OTHER 46 x.' `_ e ;6 , �f a n 1� =gip 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL h.142. YES ci 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 ID ' 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 CHECK ONE ON Y: OWNER El AGENT 0 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 1.Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PP Ii= ~= 'th:II ertine proYisio of the yy, G .•""'"�'""• PLUMBER'S NAME[STEPHEN WINSLOW .,„ ,,� LICENSE# 12298 SIGNATURE MPEl JP 0 CORPORATION Ej# 3281E 1PARTNERSHIPD#I 1LLCD#J_ COMPANY NAME 1 E.F.WINSLOW PLUMBING&HEATING I ADDRESS 18 REARDON CIRCLE J CITY 1 SOUTH YARMOUTH j STATE ZIP 02664 a-- _ TEL 508-39 -7778 FAX 508-394-8256 CELL N/A EMAIL [INSPECTIONSI EFWINSLOW.COM $ I i The Commonwealth of Massachusetts - =a Department of IndustrialAccidents 9 9 Office of Investigations $° .r 1— Lafayette City Center :=/:� 2 Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Phase 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): Ai 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(inc.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. 0 Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4.0 We are a non-profit organization, staffed by volunteers, • y with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy informatipn. **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#I. 1 am an employer that is providing workers'compensation insurance for not employees. Below is !te policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self ins. Lic.#1964A Expiration Date:0 /01/2023 Attach a copy of the workers' compensation policy declaration page(showing the policy numb r and expiration date). Failure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criinal 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 WORKORDER 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 tit,Office of Investigations of the DIA for insurance coverage verification. 1 do hereby cer ' r er the 1 ins and penalties of perjury that the information provided above I true and correct. Si natu e: . ` �7,f/" /...-.f...r- Date: 12/01/2021 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.OBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.0 Licensing Bard 50 Selectmen's Office 6.OOther Contact Person: Phone#: www.mass.gov/dia