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HomeMy WebLinkAboutBLDP & G-23-002462 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 11/4/22 PERMIT# BLDP-23-002462 I I y` JOBSITE ADDRESS 3 BELVEDERE TERR OWNERS NAME LODDERS RALPH L P OWNER ADDRESS LODDERS CAROLYN 3 BELVEDERE TERR YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES El 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 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 1Q298 SIGNATURE MP © 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 ,,,wm. CITY YARMOUTH MA DATE 10/28/22 PERMIT# tiuioFe. JOBSITE ADDRESS 3 BELVEDERE TERRACE OWNER'S NAME RALPH LODDERS POWNER ADDRESS SAME TELI508-362-2392 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT:Ej PLANS SUBMITTED: YES 0 NO FIXTURES 1 FLOOR—) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 v... . . . ii CROSS CONNECTION DEVICE NMI an MN ing I'MMI NM Mt MN UM NM iii aft- ma iiiii me DEDICATED SPECIAL WASTE SYSTEM illitiniumnitimnsinisiffinimorinriarmis DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM aim"MI I '' DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 1.111111111.111111111 an.111111111101111m. DISHWASHER 11 DRINKING FOUNTAIN 1 at FOOD DISPOSER W W I 1111.111.1111111 FLOOR/AREA DRAIN NIN MN MN INN NNW_ NM ININ INN INN on Nos N; INTERCEPTOR(INTERIOR) MatM NW iiii ow Wain IN! aii Imi lime iiiiii lam KITCHEN SINK - • ill LAVATORY `I ill ROOF DRAIN nal.ell.NE Mow ow am in.mi inn ma NM MN INN MN NM � � SHOWER STALL 1 J SERVICE/MOP SINK 'I TILET mg am gni mg amiiimi an on En 1.01 ma nig am an agi TOINAL E E r ; I —aninn WASHING MACHINE CONNECTION IIIIII WATER HEATER ALL TYPES 11131 NM NIN INN SIN INNI 1.11 INN NM NM INN INN INN ININ NMI WATER PIPING IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIwininii OTHER IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII °° IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII1. -� r IIIII IIIIIIIIIIIIIIIIIIIIIII 6 .. `E amillimi _..KINIFFINIIIIIIIIIII Niiimmilmmilini . INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ej NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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 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 with II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW _LICENSE# 12298 SIGNATURE MP0 JP[] CORPORATION 0# 3281C PARTNERSHIP _ # LLC -# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING #ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA J ZIP 02664 TEL 508 394 7778 FAX 508 394-8256_CELL N/A i EMAIL INSPECTIONS EFWINSLOW.COM MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • k' A` CITY YARMOUTH MA DATE November 04,202. PERMIT# BLDP-23-002462 JOBSITE ADDRESS 3 BELVEDERE TERR OWNER'S NAME LODDERS RALPH L G OWNER ADDRESS LODDERS CAROLYN 3 BELVEDERE TERR YARMOUTH PORT MA 02675 TEL r 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. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsaefwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ',7441;1=' CITY YARMOUTH MA DATE 10/28/22, _ PERMIT# JOBSITE ADDRESS 3 BELVEDERE TERRACE OWNER'S NAME RALPH LODDERS GOWNER ADDRESS SAME ._ ___..» J TEL 508 362-2392 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL_ EDUCATIONAL I i RESIDENTIAL LE PRINT CLEARLY NEW:u RENOVATION: REPLACEMENT: + PLANS SUBMITTED: YES 0 NO APPLIANCES 7 FLOORS-I BSM 1 2 3 4 5 6 j 7 8 9 10 11 12 13 14 BOILER I a � i BOOSTER .__ CONVERSION BURNER �.. _._ ..; 1r ,.,,,.,.. COOK STOVE DIRECT VENT HEATER DRYER 11.._ `,., . .. FIREPLACE FRYOLATOR mil- T �, �` 1.11 MI _ s FURNACE GENERATOR ,wig.am GRILLE inimonnewmairommisitiorowsnrommgior INFRARED HEATER FM 1111111011111101111ffnitillaillitill.WIIIIMIITIIIIIIIIIIIMII LABORATORY COCKS witswairsorimmintellitairellisionaltmaciortaiii MAKEUP AIR UNIT E r i i OVEN I -I I 'w.,, » ...._, i. ».» POOL HEATER _lit 1 ,,,.,.wiiiiiirialiiiiiiiriliallii ROOM/SPACE HEATER ROOF TOP UNIT TEST astsiorairestaormarammostairosimmornsitsoff UNIT HEATER t _ 'I UNVENTED ROOM HEATER ..^ 1. WATER HEATER 1 OTHER � . I � _.. a .:. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LL,1 NO LI I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY J] BOND Li 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 El 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. ��'/!1 • /./.+- Y ' PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE#412298 i SIGNATURE MP LE MGF Li JP Li JGF Ej LPG'LI CORPORATION Efj# 3281C PARTNERSHIP Lilt — j LLC # COMPANY NAME. E.F.WINSLOW PLUMBING&HEATING I 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 The Commonwealth of Massachusetts Department of Industrial Accidents 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 3.0 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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.❑ 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 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 ' R the ins and penalties of perjury that the information provided above is true and correct. Date: Signature: 7' /�--- 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): 1fBoard of Health 2.❑Building Department 3.1=1 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia