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Home My WebLink AboutBLDP-23-000931 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • CITY YARMOUTH MA DATE 8/22/22 PERMIT# BLDP-23-000931 1I 6 JOBSITE ADDRESS 38 LEWIS RD OWNER'S NAME JANOSKO RONALD E '��p OWNER ADDRESS JANOSKO MARY ANN 9 WOMPANOAG AVE NORFOLK,MA 02056 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL D PRINT CLEARLY NEW: 0 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/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❑ 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 112298 SIGNATURE MP 0 JP 0 CORPORATION ❑# PARTNERSHIP 0# LLC 0# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL I FAX I I CELL EMAIL (inspections@efwinslow.com 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK „ =fc 21— 05 3 1 = wn�=a Fi= CITY YARMOUTH MA DATE 18/12/22 i PERMIT# JOBSITE ADDRESS 138 LEWIS ROAD 1 OWNER'S NAME MARY ANN JANOSKO POWNER ADDRESS SAME * TELJ 508-775-4863 FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL 0 RESIDENTIAL El PRINT , PLANS SUBMITTED: YES Q NOEl CLEARLY NEW:O RENOVATION:Li REPLACEMENT: FIXTURES Z FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 I 12 13 14 BATHTUB I .. .. 4 CROSS CONNECTION DEVICE DEDICATED SPECIAL SYSTEM E T DEDICATED S LISAND E _IIMIIIIIMIMIIINIIIIIIIIIIIIMIIIINII MI DEDICATED GREASE SYSTEM MB I DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM .. T_. : DISHWASHER IIIIIIIIMIIMIIIUIIIIIIIBIIIIIIIII �, _...mow iimmimit DRINKING FOUNTAIN Mk PM 11111111011111110.111111110111101=1“111111Mitiligions limme INK FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR 1 m IIOIITIIIIIIII LAVATORY KITCHEN SINK MI PIIMIIIIIIIIIIIIIIIIIIIiiiiiillinilliMilli pin ROOF DRAIN MI 11.11111111111.141.101 IIIIII IIIMIIIIIIIIIII MI MOM MI SHOWER STALL ON IIIIIIIIIIIMIIIIIIMIIISIIIBIIIIIIIIIIIIINIIIMIIIIIIMIMMIIIIIIBIIIIIIIIIIIIIIIIIII; SERVICE/MOP SINK iliiiiniligniliiii110111111111 OM IIIIINIIIIIIII OM TOILET NMI_ URINAL WASHING MACHINE CONNECTION amanimo mmom sulminimmimmonsimman WATER HEATER ALL TYPES MI IIIIIIIITIMIIIIMMii _ iiiiiiiiiiiill WATER PIPING M iiinlii MIN OTHER ill _ _.Tm_. 11110.1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO Ei IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY El 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. CHECK ONE ONLY: OWNER ID 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 a 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. .r ..,. „owl.h,,,.. PLUMBER'S NAME STEPHEN WINSLOW 3LICENSE# 12298 - SIGNATURE MPL JP CORPORATION[ #13281C JPARTNERSHIPLJ#1 .. „J LLCLJ#1 __ I COMPANY NAME E.F.WINSLOW PLUMBING&HEATING j ADDRESS 8 REARDON CIRCLE ,,, CITY_SOUTH YARMOUTH STATE[ n MA ,„ ZIP 02664 j TEL 508-394-7778 _ FAX 508-394-8256 1 CELL N/A EMAIL INSPECTIONS EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents �II. /, Office of Investigations 1•q Is Lafayette City Center J . ' 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] I am a employer with 99 employees(full and/ 5. ❑Retail ---.._- -- or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.El 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 3.0 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: 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 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 ' of the ins and penalties of perjury that the information provided above is true and correct. Signature. �7... �(/......1.. 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.❑Board of Health 2.❑Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia