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Home My WebLink AboutBLDP-23-003065 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 351, CITY YARMOUTH MA DATE 12/5/22 PERMIT# BLDP-23-003065 JOBSITE ADDRESS 194 ROUTE 6A OWNER'S NAME BETTIS RICHARD LYNN P OWNER ADDRESS BETTIS MARY JANE 505 INGLESIDE AVE ATHENS,TN 37303 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:D REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ FIXTURES FLOORS—> RSM 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 12298 SIGNATURE MP ❑ JP ❑ 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@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES ,. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I'�� ' CITY LYARMOUTH --�- MA DATE 11/28/22 PERMIT# 3— �O c.'( JOBSITE ADDRESS 194 MAIN STREET G 4- j OWNER'S NAME RICK BETTIS OWNER ADDRESS SAME TEL 423-507-7765 [FAX, TYPE OR OCCUPANCY TYPE COMMERCIAL I—I EDUCATIONAL Li RESIDENTIAL El PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES',11 NO(v FIXTURES- FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 ) 14 BATHTUB 1— ~-- i . .. . _v __ CROSS CONNECTION DEVICE " W" DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM — -, NIMINIMilDEDICATED WATER RECYCLE SYSTEM r DISHWASHER DRINKING FOUNTAIN J f FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1.11,11111111111111111W11111SIIIII ........ _�.__ .... LAVATORY 1. ROOF DRAIN s I SHOWER STALL SERVICE/MOP SINK TOILET URINALMI 111.1 WASHING MACHINE CONNECTION - - ---- WATER HEATER ALL TYPES11111 r WATER PIPING lir _ OTHER I 1111111 I have a current liability insurance policy or its substantial equivalent which meets the requirements INSURANCE COVERAGE: p y q of MGL Ch.142. YES Ej 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 0 BOND 0 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 0AGENT 0 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 ertne proyisi io of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /' PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 r .0+�h-�- ` SIGNATURE MP JP CORPORATION # 3281CPARTNERSHIP # LLC0# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING " ADDRESS 8 REARDON CIRCLE CITY SOUTHRMO YAUTH -__- "` ... STATE MA ZIP 02664 2664 TEL 508-394-7778 FAX F 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 9 ��`, �( Office of Investigations �41, Lafayette City Center ! 2 Avenue de Lafayette, Boston,MA 02111-1750 '' x,� 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. [' 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. 8. ❑Non-profit [No workers' comp. insurance required] 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]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 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 • the ins and penalties of perjury that the information provided above is true and correct. 1 12/01/2021 Signature: i —. ........4,- 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 4.0Licensing Board 5.0 Selectmen's Office 6.DOther Phone#: Contact Person: www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents 9=—: —( Office of Investigations ° Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 443 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): 1.111 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. ❑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 *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#I. 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 gtiins and penalties of perjury that the information provided above is true and correct. s / 12/01/2021 Signature: Y " --A.A. — 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 3.1=I City/Town Clerk 4.0Licensing Board 5,❑Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia . . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =.51r a w��r CITY YARMOUTH.__ MA DATE:.N11/28/22 PERMIT# V S— 364° JOBSITE ADDRESS 194 MAIN STREET G. OWNER'S NAME RICK BETTIS POWNER ADDRESS SAME TEL 423-507 7765 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL Li RESIDENTIAL E PRINT CLEARLY NEW:' RENOVATION:LI REPLACEMENT:0 PLANS SUBMITTED: YES 1�� NOD FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB °I i..`� E MI CROSS CONNECTION DEVICE _k DEDICATED SPECIAL WASTE SYSTEM ( r— �� "t 1 w _ DEDICATED GAS/OIL/SAND SYSTEM i DEDICATED GREASE SYSTEMI DEDICATED GRAY WATER SYSTEM 1_. DEDICATED WATER RECYCLE SYSTEM , .... ,... ... .. ....y8..' ....�C DISHWASHER - i- p DRINKING FOUNTAIN €� _...,..._......_ �.�, A. ., �.' _( FOOD DISPOSER r p ___...._ _ .._-�. .. " .:.' FLOOR/AREA DRAIN i INTERCEPTOR(INTERIOR) :r , 1 , I in KITCHEN SINK , ------,,. -- ——V, - E , LAVATORY ` � ) , ROOF DRAIN SHOWER STALL SERVICE/MOP SINKS �' TOILET URINAL I_WW J .IM r WASHING MACHINE CONNECTION Salt ? ( WATER HEATER ALL TYPES WATER PIPING ' OTHER i 11111111111.11 .. qg INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES[] NO raj IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1, OTHER TYPE OF INDEMNITY I 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 ' 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 MP S_' JP Li CORPORATIONU# 3281C PARTNERSHIP # 1 LC D# - COMPANY NAME E.F.WINSLOW PLUMBING&HEATING 71 ADDRESS 8 REARDON CIRCLE 1 CITY SOUTH„YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256_I CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM