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HomeMy WebLinkAboutBLDP & G-23-002572 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r _n/ CITY YARMOUTH MA DATE 11/9/22 PERMIT# BLDP-23-002572 JOBSITE ADDRESS 14 ROADS END OWNERS NAME Sarah Fitzsimmons P OWNER ADDRESS MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 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 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 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 12298 SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ ice, - TI . MA DATE 11/8/22 I PERMIT# Z3 - 2 c -1 Z _ tm.. CITY-YARMOUTH JOBSITE ADDRESS 14 ROADS END OWNER'S NAME SARAH FITZSIMMONS POWNER ADDRESS SAME m._. TEL 508-619-7639 JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL ® RESIDENTIAL ET PRINT CLEARLY NEW:0 RENOVATION:® REPLACEMENT:�+ PLANS SUBMITTED: YES® NO( FIXTURES Z FLOOR-0 BSM 1 2 il 3 4 5 6 7 8 9 10 11 12 13 J 14 BATHTUB CROSS CONNECTION DEVICE ANS 111111 1111111111111MOMS DEDICATED SPECIAL WASTE SYSTEMIIIIIIMUM=1.0111.1111111MMIPMFIMIMMINIMIWOMINIMI DEDICATED GAS/OIL/SAND SYSTEM 1 *A",.. F9 IIMINE1121.15. DEDICATED GREASE SYSTEM ;. DEDICATED GRAY WATER SYSTEM ....I PIIIKIIIMIIIIIITIIIIIIIIIIF I DEDICATED WATER RECYCLE SYSTEM DISHWASHER Blinimma _ ' J DRINKING FOUNTAIN ji FOOD DISPOSER ' ... lII , --I I ig FLOOR/AREA DRAIN ' INTERCEPTOR INTERIOR) 1111110111111111•1111.111.11111111WW11.11 KITCHEN SINK 11111.111111111111111111111111M11111.11111M11111 ON OM MI LAVATORY II. ROOF DRAIN „Iii— I_ _ I t SHOWER STALL ) .e,.. __. SERVICE/MOP SINK _ , TOILET 11111111111Man liali iiM NM M MOM MI nig M URINAL m WASHING MACHINE CONNECTION :' i __ _.. WATER HEATER ALL TYPES 1 1 M WATER PIPING P . OTHER � .._ . L. • , INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES J 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 ® BOND ED 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 ® 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 li wit II ertine pro,isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .p .essAl,0-�^ PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP JP® CORPORATION 0#3281C IPARTNERSHIPD# LLC0# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A , EMAIL INSPECTIONS@EFWINSLOW.COM MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE November 09,202; PERMIT# BLDP-23-002572 JOBSITE ADDRESS 14 ROADS END OWNER'S NAME Sarah Fitzsimmons G OWNER ADDRESS MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ 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 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 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 ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER 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-GASFITTER NAME (Stephen Winslow LICENSE# 12298 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH STATE MA ZIP 026641207 TEL I FAX CELL EMAIL inspections(cilefwinslow.com w- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK c'04‘311= CITY YARMOUTH MA DATE!'11/8/22„ ----I PERMIT# Z 3— Z 5-7 2 JOBSITE ADDRESS 14 ROADS END OWNER'S NAME SARAH FITZSIMMONS J GOWNER ADDRESS SAME M TEL 508 619 7639 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL PRINT RESIDENTIAL El CLEARLY NEW: RENOVATION:Li REPLACEMENT:IA PLANS SUBMITTED: YES D NOD APPLIANCES 7. FLOORS--I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I ,,,.... ... a�`'Inn;NM I.a,,. ..,NW BOOSTER mmillaiiillintimilalitlinimigiss.(� 1 CONVERSION BURNER 11111 NM MOM COOK STOVE DIRECT VENT HEATER i f , _., DRYER I FIREPLACE FRYOLATOR FURNACE liillill 0111110111110111111011.1111.11111111111.10,1.iNMI Olt riorimi GENERATOR GRILLE1111111111.11111111111111111111W11111,111.1111111.1.1111.11111111.1111111 INFRARED HEATER amilarliii Momicaitallim ail Inif OM INK; 111111111111 NNW LABORATORY COCKS aimisiffaii mos aim ow MAKEUP AIR UNIT OVEN Iniallinnilitilliti , ......,, wl . POOL HEATER , .11111.111. ROOM/SPACE HEATER , on NNW ROOF TOP UNIT TEST 1111111 1 UNIT HEATER 0111111M111111110111011111111111M011110.1111111111111111111111111N°illillin NW UNVENTED ROOM HEATER 11111.111MIMOIM11111.0111110111111.1111111111011111 MOW,' WATER HEATER OTHER . . gl= INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 14.1 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2j OTHER TYPE INDEMNITY I 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 Li 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 and accurat to the b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc a dine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r�✓ • li/�- PLUMBER-GASFITTER NAME STEPHEN WINSLOW Y '~ • --, LICENSE# 12298 SIGNATURE MP Ej MGF D JP Li JGF Li LPG' CORPORATION Lij#3281 C PARTNERSHIP Ll# LLC 0# COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY [SOUTH YARMOUTHI STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts y Department of Industrial Accidents M s'° Office of Investigations 7 _" •: ' Lafayette 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): 1.0 I am a employer with 99 employees (full and/ 5. 0 Retail 2.0 or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 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 10.0 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: 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 ' ei the ins and penalties of perjury that the information provided above is true and correct. Signature: 7' '` - "-- 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): 1OBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.0Licensing Board 5.0 Selectmen's Office 6.[]Other • Contact Person: Phone#: www.mass.gov/dia