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HomeMy WebLinkAboutBLDP-21-005701 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �° CITY YARMOUTH MA DATE 4/2/21 PERMIT# BLDP-21-005701 1-1-=4' JOBSITE ADDRESS 77 RAYMOND AVE OWNER'S NAME BOTTO CLAUDIA KOPF rA1,= _ P OWNER ADDRESS BOTTO EDWARD L 51 MORAINE RD MORRIS PLAINS,NJ 07950 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ NO El 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 ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El BOND El 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 El CORPORATION ❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP ,026641207 TEL FAX CELL EMAIL inspections@efwinslow.com sss Is ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ FEES$ PERMITS PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '' ��'� CITY v I + MA DATE L ! PERMIT # T��'AMR' , .. f.a viz._ a�..,.....,a... JOBSITE ADDRESS ?i ILtraii IA OWNER'S NAME ,,,,ci J)p -. , ^- . „J p .�_LL_�_.._ f f OWNER ADDRESS �rl�ur��%t� ,Q��n��r`���•��n5�._�.� d�Z� SO � TEL � ��6.� FAX _ _ ��: TYPE OR OCCUPANCY TYPE COMMERCIAL [J EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: U . RENOVATION: 1 REPLACEMENT: Ei PLANS SUBMITTED: YES 0 NOID FIXTURES 7. FLOOR—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB L..: _: .:. .�.,,,,,;, . .;� __.: . ._ L-�..3C.-._.�.�...�F. _l_ ._.. I . . ; _ �� ._ -. - .-_ ' :.�_ ` _ ,��, --; CROSS CONNECTION DEVICE1 . . . f _: _ _ 1 �. 11111111[ -`I; ___. DEDICATED SPECIAL WASTE SYSTEM MIIIIIIMF-11MMINial aggiMMIWOIm Mum" DEDICATED GAS/OIL/SAND SYSTEM gurigumuniguinwiwiltilleggigagglimpaigui GREASEDEDICATED 00L-- IHrriti riahla1=11 -I.M.1-Hin..='1111111111111111111,7=411111111' DEDIC Ill MMM.INIA ► ' WATER RECYCLE .:.." r i 'r : :d om DISHW lin Am, - MM J ..-_-- • ■ rM 711Elli _______ ----71 __ ' j L ^ rr ` �_ �` `FOOD PO __ _T , _Ji = i r?- 1; 'I KITCHEN SINK mommi4,11Mil ,1 _ Ili --li _ ,____ ! : It __:I • • STALL ingiguegigiggigumwourimugunggiumillingt SERVICE / MOP SINK III ;� III1L_J LII MACHINEWASHING I ,I .�_ ,4 I _ k r l I ,. 1 ;: ,!____Jillit ' _ _ I WATER PIPING INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 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 J 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 Ii with II ertine provisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW _ 1 LICENSE # [i2298 I SIGNATURE 4...+1". „r, S. MP[ JP .._. CORPORATION A# 3281C PARTNERSHIPLI# :_ _ LLCLJ#F _.._1 %- s COMPANY NAME E,F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY[SOUTH YARMOUTH JSTATE i MA l ZIP [02664 I TEL 508-394-7778 _..- FAX L508-394-8256 J CELL [N/A —1 EMAIL I INSPECTIONS@EFWINSLOW.COM �'�� The Commonwealth of Massachusetts Department of Industrial Accidents ii=_.,z1_ Office of Investigations mill'— 6 Lafayette City Center =:=7 ,i 2Avenue de Lafayette,Boston,MA 02111-1750 ' `°y 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 90 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.ElWe 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:01/01/2022 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 ' ef the glZins and penalties of perjury that the information provided above is true and correct. Signature: Y Date: 01/02/2021 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.❑Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia The Commonwealth of Massachusetts s Department of Industrial Accidents =z ; Office of Investigations =a . Lafayette City Center �w�i i l ma 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): 1.0 I am a employer with 90 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]** 11.❑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:01/01/2022 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer '���the��i�s��nd'penalties of perjury that the information provided above is true and correct. Signature: Y Date: 01/02/2021 Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1.❑Board of Health 2.❑Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .r ,12_ tD CITY[...... . ....�4,IM11 1J '�1. ,._, . __. .-.. MA DATE I /12/ I 1 PERMIT# . I,, JOBSITE ADDRESS 11.Ra y>hD? Alit. . So,J' \laiina✓ki 1 OWNER'S NAME yEJ 13040 POWNER ADDRESS 'l Mu/a;f1 K I/4 r P�•�v15 /� OZa SQ TEL 5�� tl � & FAX .. I TYPE OR OCCUPANCY TYPE COMMERCIAL U EDUCATIONAL 0 RESIDENTIAL[` ---- PRINT CLEARLY NEW:Li RENOVATION:El REPLACEMENT: ,._ PLANS SUBMITTED: YES Li NO[ FIXTURES Z FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 A _. ___1____ __ _A _ _____1 CROSS CONNECTION DEVICE ) I L. I- DEDICATED SPECIAL WASTE SYSTEM i DEDICATED GAS/01USAND SYSTEM DEDICATED GREASE SYSTEM _ 'L DEDICATED GRAY WATER SYSTEM I,_: I- I,___ _-=1 - -I- i=- .1--- __ ___ I --_ ! _.i DEDICATED WATER RECYCLE SYSTEM � ,(�� 1ligftilliPlitit DISHWASHER , __ , I i, ' DRINKING FOUNTAIN t( L i ! t , i ' FOOD DISPOSER _ `1. L,.,-_4 1 i i - —_� ., f FLOOR 1 AREA DRAIN .... INTERCEPTOR(INTERIOR) IE-- t 1 1i KITCHEN SINK + li ( i t LAVATORY ,1 L i , ROOF DRAIN r--- �� .__ I SHOWER STALL ' SERVICE I MOP SINK ! I TOILET 1 I [ -i . URINAL iØ$ 1 1 L l � I E INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES DI NO [ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY Ej BOND fl 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 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 '''4:34 and that all plumbing work and installations performed under the permit issued for this application will be in co li with II ertine pro'isioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7r --` .44.,47 r 0,-...... PLUMBER'S NAME[STEPHEN WINSLOW LICENSE# 12298 SIGNATURE .11 s MPD JP Ej CORPORATION[JP 3281C PARTNERSHIP[...__lit LLCI.,..,.'1# J COMPANY NAME LE.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE s, CITY SOUTH YARMOUTH STATE MA ZIP [02664 1 TEL 508-394-7778 ^FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM