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HomeMy WebLinkAboutBLDP & G-23-002888 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ^� CITY YARMOUTH MA DATE November 28,202; PERMIT# BLDP-23-002888 it 54 JOBSITE ADDRESS 64 WIANNO RD OWNER'S NAME BRAZEAU JOHN A G OWNER ADDRESS BRAZEAU SUSAN A 64 WIANNO RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES 0 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 Q JP❑ JGF❑ LPGI ❑ 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(a),efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r= 7�c `:�"1_iyT CITY I YARMOUTH MA DATE 11/18/22 PERMIT# 2. 2 — 9 JOBSITE ADDRESS 64 WIANNO ROAD OWNER'S NAME 'JOHN BRAZEAU GOWNER ADDRESS SAME_ . _ _ ___ _ TE 774 994 8505 FAX TYPE OCCUPANCY TYPE COMMERCIALS EDUCATIONAL ,n...j RESIDENTIAL Lj CLEARLY PLANS SUBMITTED: YES NOS NEW: RENOVATION:L m REPLACEMENT: . APPLIANCES 1 FLOORS—, BSM 1*j 2 3 4 5 6 7 8 9 10 11 12 I 13 14 BOILER .., u,.81c BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I ......... DRYER F r 1 t FRYOLATOR1 t . . FURNACE »... GENERATOR OM 11.1 INFRARED HEATER - LABORATORY COCKS mantimmoramossmimmiimimeori- MAKEUP AIR UNIT OVEN _.. . POOL HEATER � M_ w ROOM I SPACE HEATER ROOF TOP UNIT MRIMIIIIIIIMIIIIIIIIMIIIR ... .. _ UNIT HEATER UNVENTED ROOM HEATER OK 1111111 rail all WATER HEATER OTHER 8 . . _ i € r INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1::;_l OTHER TYPE INDEMNITY L v. 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 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 rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �`r/%1 • �i/.�- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 _ SIGNATURE MP L MGF 0 JP JGF LPGI J CORPORATION + # 3281C PARTNERSHIP L # _ LLC # COMPANY NAME. E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY 1 SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A 3 EMAIL INSPECTIONS@EFWINSLOW.COM MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK , c, CITY YARMOUTH MA DATE 111/28/22 PERMIT# BLDP-23-002888 JOBSITE ADDRESS 164 WIANNO RD OWNER'S NAME IBRAZEAU JOHN A n OWNER ADDRESS BRAZEAU SUSAN A 64 WIANNO RD YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:0 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 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 1'2298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# ( I COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY IS YARMOUTH STATE IMA ZIP 02664 TEL 5083947778 FAX CELL EMAIL (inspections@efwinslow.com I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • �kf R� CITY YARMOUTH MA DATE 11/18/22 PERMIT# 7--5 r -1- 9 I JOBSITE ADDRESS 64 WIANNO ROAD J OWNER'S NAME JOHN BRAZEAU POWNER ADDRESS SAME i TEL 774-994-8505 -FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL Ej RESIDENTIAL LI PRINT CLEARLY NEW:Ei RENOVATION:Li REPLACEMENT:Ej PLANS SUBMITTED: YES® NO FIXTURES-1 FLOOR-i BSM 1 2 3 J 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE Iliniii MOM NIB Millmiiiiimmis NMNils min nimmons - s DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEMNM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN ;MM..ineinginii, INTERCEPTOR(INTERIOR) ' m KITCHEN SINK —Minraiii MB IMO MU 1111111M111114.1111 MI MN UM 111111011111=1111111 LAVATORY ROOF DRAIN SHOWER STALL NINIMIIRIIIIIMIIIIIFIIIIMIIIIMIIIIMIIIIIFIIIIIIIWIIIIIOIIIIFIIIIIIIMIIIIIIIIIIII SERVICE I MOP SINK TOILET MI URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 INIUMMI ail MN NM 1111111MMINII.MM.MI 111111M11111MM WATER PIPING OTHER MI I IIIIMIIIIIIIIIIIIIEIIIIUIIIIIIIMIIIIIIIIIIIOIIIIIIPIIIFMIIEIIIIIIIIMJIIE INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ej NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY J OTHER TYPE OF INDEMNITY 0 BOND Ej 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 Ej 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 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 LICENSE# 12298 ~� SIG NATURE MP Lj JP Ej CORPORATION El# 3281C _PARTNERSHIP Ej#r, ILLCD# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE I CITY SOUTH YARMOUTHy STATE MA ZIP 02664 TEL�508 394 7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents A=^.� Office of Investigations 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.® I am a employer with 99 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 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.❑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 *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 cer ' e the ins and penalties of perjury that the information provided above is true and correct. Signature: /? /,..,,•l..r- 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): 1.133oard of Health 2.❑Building Department 30 City/Town Clerk 4.['Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia