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HomeMy WebLinkAboutBLDP&G-22-004779 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 2/28/22 PERMIT# BLDP-22-004779 JOBSITE ADDRESS 24 GROVE ST OWNER'S NAME QUINLAN DONALD F TR P OWNER ADDRESS QUINLAN PATRICIA A TR 11 GROVE ST WEST YARMOUTH,MA 02673 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 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 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 112298 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC El# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY SYARMOUTH STATE MA ZIP 026641207 TEL 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 4muw. .__.. _-.._w.w..w- .w...........w _..- w.w----- al i IWEST as CITY YARMOUTH MA DATE 2121/22 PERMIT # .21 LI(-1-1`) JOBSITE ADDRESS 24 GROVE STREET OWNER'S NAME: DONALD QUINLAN OWNER ADDRESS SAME TEL 508 367 0372 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL [1 EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: El RENOVATION: m , i REPLACEMENT i PLANS SUBMITTED: YES NO FIXTURES -1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB r E _ 7 i ---1,-- ! -_ .T. _.w_.---- .w ,, .w , . CROSS CONNECTION rilirMalF1111.1-111111IINTMallitalit DEDICATED SPECIAL WASTE SYSTEM r , DEDICATED GAS/OIL/SAND SYSTEM 1-"- DEDICATED GREASE SYSTEM 1 N ;D _ y� DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM �� DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER . iw -1 w w N ., g _ . .. j . . . I m , FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) . . KITCHEN SINK `. . LAVATORY ROOF DRAIN SHOWER STALL 1--- 111111NIMIlliiiii . . SERVICE / MOP SINK ' #I ww� E 1 TOILET URINAL I WASHING MACHINE CONNECTION IIIIIIIIIIITNIIIMIIIIIIUIIMIIIIINIMIIIIIIIIIIIEMIIMIIf1111111111111111Miall WATER HEATER ALL TYPES : WATER PIPING IIIMIIIIIIMIIIIIIIMIIIIIIMM OTHER 0 P >, E •, &E a .. p ., .. 'w... w... '... a �S .: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES r NO �w IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Li 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. CHECK ONE ONLY: OWNER I i 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 lia with II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I STEPHEN WINSLOW w w LICENSE # 12298 rWtlemm4I SIGNATURE MP i ` JP 0 CORPORATION :A# 3281C mm PARTNERSHIP,- # LLC ,# COMPANY NAME 1 E.F. WINSLOW PLUMBING & HEATING j ADDRESS 8 REARDON CIRCLE „_.„,„________ _ , _______i CITY SOUTH YARMOUTH 1 STATE MA i ZIP 02664 i TEL 508-394-7778 FAX i 508-394-8256 CELL N/A 1 EMAIL ! INSPECTIONS@EFWINSLOW COM The Commonwealth of Massachusetts 9,==-6 " Department of Industrial Accidents _.. Office of Investigations Lafayette City Center 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.❑■ 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]** 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 *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 phins a, nd penalties of perjury that the information provided above is true and correct. Signature: 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): I.❑Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.El Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK s f CITY YARMOUTH MA DATE "February 28,2022 I PERMIT# BLDP-22-004779 JOBSITE ADDRESS 24 GROVE ST OWNER'S NAME 'QUINLAN DONALD F TR G OWNER ADDRESS QUINLAN PATRICIA A TR 11 GROVE ST WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES 0 NO❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 OF INDEMNITY': 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 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-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP©MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY IS YARMOUTH I STATE MA ZIP 026641207 TEL FAX CELL EMAIL Iinspectionsnaefwinslow.com SALON M3IA32i NVId #.IW2i3d $ :33d ❑ ❑ 1.11M1DEd 3H1 SV S3M3S NOIIV3IlddV SIHl oN saA S310N N01103dSNI 1VNId AlNO 3Sl 210103dSNI 2iO3 3OVd SIH1 S31ON NOI103dSNI SVO HOf102i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ._ _ r• CITY WEST YARMOUT MA DATE. 2/21/*22 1 PERMIT # JOBSITE ADDRESS 24 GROVE STREET OWNER'S NAME s DONALD QUINLAN G OWNER ADDRESS SAME 1 TEL 508 367 0372 FAXµ TPRP OR OCCUPANCY TYPE COMMERCIAL , EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION: I REPLACEMENT: v PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER Ig I CONVERSION BURNER COOK STOVE DIRECT VENT HEATER . ......ii-------- , DRYER ,� 1 ,„ • .,r S C araaaaa. t ,, w .w._w..-, .. FIREPLACE FRYOLATOR FURNACE GENERATOR , GRILLE _. ... INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN 11 POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER ii WATER HEATER 1 OTHER_ 11 •: i - Aa�aauwvu,aaaacw�.uaar...r,�aoaacaam.,a..aHaa,:w�.:a. .u.. ..;:. . ...... y .,., .,.... _ ... ., INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES is.v,i NO Li I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ` / OTHER TYPE 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. 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 and accurat to the b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ` / PLUMBER-GASFITTER NAME i STEPHEN WINSLOW LICENSE # 12298 SIGNATURE 1. MP MGF [[ JP JGF LPGI CORPORATION ' # 3281C PARTNERSHIP # LLC # a euam�,:...3w.c,,.whson.:,can COMPANY NAME:LE.F. WINSLOW PLUMBING & HEATING ADDRESS; 8 REARDON CIRCLE ..d.:5:.:. :..:. :.h 'M:amwav aKaC WCs. CY,9.s. •.a ,....ON NRNC:Hac—..... ....,,:sAuaiS.vS &ss n:.........—.5''\ "C.aY. 9nL`e...A\,xNi....,:,',......Ad....,,,,.......4..., CITY SOUTH YARMOUTH STATE MA ZIP 2664 ITEL 508 394-7778 FAX' 508-394-8256 CELL N/A EMAIL! INSPECTIONS@EFWINSLOW COM ti The Commonwealth of Massachusetts Department of Industrial Accidents 1r�, —; ►_1' Office of Investigations Lafayette City Center =� 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): Lk 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. El 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.III, We are a non-profit organization, staffed by volunteers, 11.❑ 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 and penalties of perjury that the information provided above is true and correct. ' / 12/01/2021 Signature: ? ' 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.❑Licensing Board 5U Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia 111\- The Commonwealth of Massachusetts Department of Industrial Accidents =,. Office of Investigations Lafayette City Center wave 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.© 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]** 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 *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 ce ' e1 the ins and penalties of perjury that the information provided above is true and correct. 12/01/2021 Signature: 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 5.1=1 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK = CITY WEST YARMOUT MA DATE F 21211'22 PERMIT# JOBSITE ADDRESS:24 GROVE STREET OWNER'S NAME LDONALD QUINLAN OWNER ADDRESS LSAME TEL 508 367 0372 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL I RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: ' PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS—. BSM 1 2 3 4 I 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [D NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I IABI ITY INS RANCE POLICY OTHER TYPE 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. CHECK ONE ONLY: OWNER AGENT r 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 accurat to the b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc a rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� / %1 • !/ PLUMBER-GASFITTER NAME,STEPHEN WINSLOW LICENSE#.12298 SIGNATURE MP MGF JP JGF LPG1i CORPORATION # 3281C PARTNERSHIP '# LLC # ,441 COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE E MA ZIP 02664 ITEL:508-394-7778 FAX 508-394-8256 CELL:NIA EMAIL INSPECTIONS@EFWINSLOW.COM