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Home My WebLink AboutBLDP-22-005305 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' F CITY YARMOUTH v MA DATE 3/23/22 PERMIT# BLDP-22-005305 m. rm JOBSITE ADDRESS 15 SAMOSET RD OWNER'S NAME Elizabeth Myers P OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY ROOF DRAIN SHOWER STALL 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❑ 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#Q298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 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 =v ,' CITY YARMOUTH(SOUTH) MA DATE 03/21/2022 PERMIT# 22 $3Of JOBSITE ADDRESS 15 SAMOSET RD,S.YARMOUTH,MA 02664 OWNER'S NAME ELIZABETH MYERS I POWNER ADDRESS 11 OCEAN WOODS DR W,ST.AUGUSTINE,FL 32080 I TEI (904)615-7986 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL [Ti RESIDENTIAL PRINT CLEARLY NEW:Li RENOVATION:Li REPLACEMENT:I v l PLANS SUBMITTED: YES LI NOL] FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE III ,,, p , iiinn , , ni T iii,min DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM , il:11 ,111111=1111111. FIlliFirii DEDICATED GREASE SYSTEM I I DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER r : DRINKING FOUNTAIN �� ' FOOD DISPOSER FLOOR/AREA DRAIN FM,11111111111111111 MAIN mem am rell um am 11111 gm NMI imp INTERCEPTOR(INTERIOR) AINIIMMIIIIIIIIIIIIMAIWNpilkallitiMAIMIR KITCHEN SINK LAVATORY =Minna nonalusiniunt ROOF DRAIN Eximmimp l� l all 1111.MI 1111155 SHOWER STALL SERVICE/MOP SINK MI � -- 'IMMIX. 1,111.10 TOILET Ialli1111111.1111111 NMI 7111! II I II I MIN WASHING MACHINE CONNECTION URINAL11111111111111111111 d1,1!III! WATER HEATER ALL TYPES a , WATER PIPING -= OTHER 1 r. lismil-11111111 . MO 1111 11 .... 111111111.11111111.11111.111111111111111...111111111M1111111111111111111111111111111111.111111111111111111111111111111111 INSURANCE COVERAGE: 1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO Ti IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ri OTHER TYPE OF INDEMNITY Li 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. CHECK ONE ONLY: OWNER ED AGENT 0 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 G. — -- - - SIGNATURE MP . JP El CORPORATION0#13281C PARTNERSHIP #f LLCL#I COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY I SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394 7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW COM Z'' The Commonwealth of Massachusetts Department of Industrial Accidents jg ti Office of Investigations Lafayette City Center ;jt 2 Avenue de Lafayette, Boston, MA 02111-1750 " =1 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. ❑ 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, 11.0Health 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 the ins and penalties of perjury that the information provided above is true and correct. Signature: 7' "` --w"'`-�' Date: 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): 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia