The URL can be used to link to this page

Home My WebLink AboutBLDP-23-002912 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ). *_; , " CITY YARMOUTH MA DATE 11/28/22 PERMIT# BLDP-23-002912 l l .57 ADDRESS 7 JONES RD OWNER'S NAME DEMEO JOHN A TR D' OWNER ADDRESS ISEVEN JONES RD RLTY TRUST 3909 DANCE MILL RD PHOENIX,MD 21131 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ FIXTURES z 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❑ 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 El 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 I LICENS412298 SIGNATURE MP 0 JP ElCORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑# I COMPANY NAME ISTEPHEN A WINSLOW ADDRESS 18 REARDON CIR 8 REARDON CIR I CITY IS YARMOUTH I STATE MA I ZIP 102664 I TEL 15083947778 FAX I I CELL I I EMAIL (inspections@efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK F .4;x _c., i r = E- CITY YARMOUTH Z -_s�kl= MA DATE 11/18/22 PERMIT# Z3 y 5 i Z JOBSITE ADDRESS 7 JONES ROAD OWNER'S NAME JOHN DEMEO P OWNER ADDRESS SAME TEL 410-371-4024 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL _.. RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION: REPLACEMENT:El PLANS SUBMITTED: YES Ej NO FIXTURES-1 FLOOR—, BSM 1 2 3 4 5 6 7 1 8 1 9 .l 10 11 I 12 13 14 BATHTUB CROSS CONNECTION DEVICE mm : DEDICATED SPECIAL WASTE SYSTEMaii10011 mr011111 a=mumillIII MM.iminiramillilli= DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM 11111.` DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER NM MI NW NM MI NMI 01111.111111 MIR IIIIIINIIMIAIMIII DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK r T . LAVATORY Set ROOF DRAIN 1 11111 SHOWER STALL SERVICE/MOP SINK _ TOILET �.. .�. � .a n � ��-, _ .. -r URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING IMIIIKIIWIIIMINIOIIIIFIIIIIIMIUIIIIFIIIIMIIIIIFIIIIIIJIIIIIINIIIIIIIMW OTHER 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 0 OTHER TYPE OF INDEMNITY 0 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 0 AGENT Li 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 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 proyisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. </ PLUMBER'S NAME STEPHEN WINSLOW � LICENSE# 12298 SIGNATURE � MP El JP El CORPORATION 0# 3281C PARTNERSHIP El# . LC El# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE I ._ MA I ZIP 02664 1 TEL 508 394 7778 FAX 508-394-8256 j CELL N/A I EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts �...'' Department of Industrial Accidents + �® Office of Investigations Lafayette City Center a t 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): I.0 I arrrwemployei with 9g- employees--(full and'- -5---❑Retail _--- ---- ----------or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. Office and/or° ' s(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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care 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 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:01/01/2023 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 impositionof 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 cer • e the ins d penalties of perjury that the information provided above is true and correct. Signature: ` T / 12/01/2021 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): 1fBoard of Health 2.1=I Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia