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Home My WebLink AboutBLDP-23-004087 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ^_ CITY YARMOUTH MA DATE 1/24/23 PERMIT# BLDP-23-004087 t 1. JOBSITE ADDRESS 923 ROUTE 6A UNIT M OWNER'S NAME Mellissa Alden P OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURFS 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 2 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING , OTHER 3 OTHER DESCRIPTION: REPLACE PVC WITH COPPER 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 0 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 112298 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 r a uFf CITY YARMOUTH MA DATE! 1/19/23 PERMIT# _ ?-7 JOBSITE ADDRESS 923 MAIN STREET/ROUTE 6A UNIT M i OWNER'S NAME ALDEN&WATSON LAW P OWNER ADDRESS PO BOX 488 YARMOUTH PORT,MA 02675 TEL 508 744 7291 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL ® RESIDENTIAL 0 PRINT CLEARLY NEW: RENOVATION:ID REPLACEMENT:ID PLANS SUBMITTED: YES 0 NOID FIXTURES 7 FLOOR-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB r CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM f i' DEDICATED GAS/OIL/SAND SYSTEM intairiminumilimir pluirolor mum lilt DEDICATED GREASE SYSTEM NON INN NMI NIMMININIIIIIIMmi INN MN IIIIIMININ NMI DEDICATED GRAY WATER SYSTEM i I — M DEDICATED WATER RECYCLE SYSTEM f "7- I �- fi DISHWASHER � -ilia` ' DRINKINGISHWA FOUNTAIN M our iiirommuir lilt FOOD DISPOSER 4 FLOOR/AREA DRAIN k' INTERCEPTOR(INTERIOR) KITCHEN SINK • LAVATORY ROOF DRAINlialiiiiii.111 NM NM IiiiiiMiiii Mini SHOWER STALL 11111 i fligninixiimiii IIM - IMI jig SERVICE/MOP SINK TOILET 2 URINAL11: , , WASHING MACHINE CONNECTION N Mil illii WATER HEATER ALL TYPES 11111 INIMMINIMININ ems inommummumiamis gm mum am WATER PIPING 2�� it OTHER BATHROOM DRAINS pig an muff KITCF111DIRAIN NW linftligIVIIIIMINI all 1111.1.111MMINION NM NMI NM NM MIR INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO Li IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY fJ 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 CHECK ONE ONLY: OWNER 0 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 Ii wit II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW r ff LICENSE#[12298 SIGNATURE MP JP® CORPORATION 0#J3281C JPARTNERSHIPO#1 LLC[ #i 1 COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 1 TEL 508-394-7778 FAX 508-394-8256 CELL IN/A EMAIL INSPECTIONS EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents tea= 1 Office of Investigations til w �� Lafayette City Center At = '= 2Avenue de Lafayette,Boston,MA 02111-1 750 , `."' 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-Iii I am a employer with 120 employees (fi,ll and/ 5. ❑Retail or part-time).* 6. Ej Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor o- `rtnership and have no employees working for me L.. ny capacity. 7 ❑Office and/ gales(incl.real estate,auto,etc.) [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]** 4.0 We are a non-profit organization, staffed by volunteers, 11.0 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. #2019AExpiration 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 fme 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 fme 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 cer ' rf the ins and penalties of perjury that the information provided above is true and correct. Signature: r t ......./..r.• 01/01/2023 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): I.OBoard of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia