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Home My WebLink AboutBLDP-22-007434 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK p CITY 'YARMOUTH MA DATE 6/27/22 PERMIT# BLDP-22-007434 '- JOBSITE ADDRESS 964 ROUTE 6A OWNERS NAME John nash D OWNER ADDRESS 964 ROUTE 6A YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 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 1 SERVICE/MOP SINK _TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 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 0 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❑ 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. PLUMBERS NAME Stephen Winslow LICENSE 1'2298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY IS YARMOUTH I STATE MA ZIP 026641207 TEL FAX I I CELL I I EMAIL inspections@efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 41.. - CITY YARMOUTH MA DATE 6/24/22 1 PERMIT# 'L�'- `� 3 Li a u i —�h JOBSITE ADDRESS 964 RT 6A,YARMOUTH PORT,MA 02675 I OWNER'S NAME JOHN NASH POWNER ADDRESS SAME TEL 617 780-4044 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL .. EDUCATIONAL E3 RESIDENTIAL PRINT CLEARLY NEW:ID RENOVATION:11_ REPLACEMENT:LI PLANS SUBMITTED: YES EI NO[] FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSSan _ , • • to D • ', ik 1 :iN DEDICATED GAS/OIUSAND SYSTEM 1111110111111111111111111111411111111111111111111111411111111111111111111111111111111.111111111111111 DEDICATED GREASE SYSTEM DEDICATED - DEDICATED . .ECYCLE SYSTEM am, _ „ in_ ininionr,.. _ inni__ .wintini, imm.limummtlimiali DISHWASHER DRINKING FOUNTAIN l i' FOOD DISPOSER _._ l 1 _. .. I W. FLOOR/AREA DRAIN �E _.. �_. . . ._ __ ' _ _ �i _ _ 1 INTERCEPTOR(INTERIOR) li :f KITCHEN SINK , € LAVATORY ( : ROOF DRAIN r I SHOWER STALL 1 a l I` SERVICE/MOP SINK TOILET . r URINAL ,1 WASHING MACHINE CONNECTION E eE i WATER HEATER ALL TYPES 1 WATER PIPING n ! I OTHER • _ • E 1 - - - -- - -- , , 11 ( URRURURURUR , .,, , ,, INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITY ED BOND Q 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 SIGNATURE OF OWNER OR AGENT ® 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. Y �. PLUMBER'S NAME STEPHEN WINSLOW ..•.�� LICENSE# �12298_ SIGNATURE MPD JP0 CORPORATION Q# 3281C PARTNERSHIP[,# LLCD# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE I CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX [508-394-8256 CELL N/A I EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts _ _ Department of Industrial Accidents 1= r., 4 = an_ Office of Investigations Lafayette City Center '" " 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): 1.El I am a employer with 99 employees (full and/ 5. ❑Retail 2.0 or part-time).* 6. E j Restaurant/Bar/Eating Establishment I am a sole proprietor or partnership and have no 7. El 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. 0 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 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: C I' .......� 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.OBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.[]Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia