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Home My WebLink AboutBLDP-22-006121 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK u _ _ CITY 'YARMOUTH MA DATE 4/25/22 I PERMIT# BLDP-22-006121 IE= .- JOBSITE ADDRESS 188 OCEAN AVE I OWNER'S NAME IBUSCHMANN DALE M I P OWNER ADDRESS 188 OCEAN AVE SOUTH YARMOUTH,MA 02664 I TEL I I TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 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 1 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 El NO El 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 I LICENSEIV2298 I SIGNATURE MP ❑ JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# I I Lc ❑# I I COMPANY NAME ISTEPHEN A WINSLOW I ADDRESS 18 REARDON CIR CITY IS YARMOUTH I STATE !MA I ZIP 1026641207 I TEL I FAX I I CELL I 1 EMAIL (inspections@efwinslow.com I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 111 i® CITY YARMOUTH(SOUTH) i MA DATE 04/21/2022 I PERMIT# 22- C.I1-( JOBSITE ADDRESS 88 OCEAN AVE,S YARMOUTH,MA 02664 OWNER'S NAME DALE BUSCHMAN OWNER ADDRESS SAME TEL (561)385-6284 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ill EDUCATIONAL [I RESIDENTIAL 0 PRINT CLEARLY NEW:0 RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES D NOD FIXTURES 1 FLOOR-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE `S 'IIDEDICATED SPECIAL WASTE SYSTEM i JormAii_ finire, 1,mm' I DEDICATED GAS/OIL/SAND SYSTEM lilt 1 i ME1 all IM1 DEDICATED GREASE SYSTEM ? immomplaussamimaimmi DEDICATED GRAY WATER SYSTEM i , DEDICATED WATER RECYCLE SYSTEM ( u1 Mt-maimitmaiiton, , DISHWASHER C _ W DRINKING FOUNTAIN , i FOOD DISPOSERn„,,,0",..,11,-,..iiii"... ...,F.,,,,,,. .., FLOOR/AREA DRAIN 3 INTERCEPTOR(INTERIOR) 111,011111111111111.1.KITCHEN SINK illn of elli', : lima low LAVATORY ROOF DRAIN ..iniiiiiriii El' 11 11, SHOWER STALL I lin I Rion 1 i SERVICE/MOP SINK IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMMOIIIIIIIIIII TOILET URINALnannsions anann WASHING MACHINE CONNECTION ' W iMIR I III! NB Mit ' WATER HEATER ALL TYPES I I ?Iiiilliffahlil,1111111, I ' . WATER PIPING 1 OTHER Il '1111111 nonlammiliati , 1 an , , , , ,„ . .. .. ,..„asi imaiuminmim,..., R,... INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO ri 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 CHECK ONE ONLY: OWNER 0 AGENT [I I hereby certify that all of the details and information I have submitted or entered regarding this application are true r to 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 proYisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW r 0•'�"�^ _. _._ , _ LICENSE#[12298 _ SIGNATURE MPLI JP El CORPORATION El 3281C PARTNERSHIP[ K LLC0# COMPANY NAME L E.F.WINSLOW PLUMBING&HEATING i ADDRESS[8 REARDON CIRCLE CITY SOUTH YARMOUTH _ STATE . MA ZIP 02664 TEL 508-394-7778 FAX 1508-394-8256 i CELL[N/A 1 EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents r Office of Investigations Jot l i��j Lafayette City Center ` 2 Avenue de Lafayette, Boston, MA 02111-1750 '"' =` wwx.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. ❑ 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. III 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.❑ 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 ' e the ins and penalties of perjury that the information provided above is true and correct. , / Signature: 1' ^• ,...4.L- 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.DBoard of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia