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HomeMy WebLinkAboutBLDP&G-22-004123 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -�� CITY YARMOUTH MA DATE [1/25/22 PERMIT# BLDP-22-004123 mar,-j JOBSITE ADDRESS 11 COLLINGWOOD DR OWNER'S NAME AFRAME JAY Z P OWNER ADDRESS AFRAME MYRA 8 27 BARRY RD WORCESTER,MA 01609 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL 0 PRINT CLEARLY NEW:D RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ FIXTURFS FLOORS—a 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❑ 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❑ 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 10298 SIGNATURE MP 0 JP 0 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 4 a — "�" CITY YARMOUTH (PORT) MA DATE 1/18/22 PERMIT # z� I - JOBSITE ADDRESS 11 COLLINGWOOD DRIVE - OWNER'S NAME JAY AFRAME P OWNER ADDRESS SAME ? TEL! 508-981 0401 ,FAX TYPE OR OCCUPANCY TYPE COMMERCIAL P- EDUCATIONAL RESIDENTIAL 21 PRINT ` CLEARLY NEW ' ' RENOVATION: REPLACEMENT � PLANS SUBMITTED: YES NO, ; FIXTURES Z FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I -- , CROSS CONNECTION DEVICE i_. 3 ;° ' .._ _. . r I DEDICATED SPECIAL WASTE SYSTEM I I DEDICATED GAS/OIL/SAND SYSTEM -.Ililt 1 I DEDICATED GREASE SYSTEM 11 ' ' --- DEDICATED GRAY WATER SYSTEM J) 1 € � DEDICATED WATER RECYCLE SYSTEM IMO"IIIIIIIIIINIIIIIEIIIRIIIIIIMIMEIIIMMIIIIIIIIMl DISHWASHER iI _ DRINKING FOUNTAIN 1111111111a111111111N11111111111111.111. i 111111111111111MMIM FOOD DISPOSER _ M11 111111111111.1 IIMIMMIME111.11111.111M011111111111111M1 FLOOR /AREA DRAIN .IIIIIFMIIIINIIIIIIIMIIIIIIIIIMIINIIIIIIIIIIIIW: INTERCEPTOR (INTERIOR) NM I MIN MIMI"MIN OMNI WilltM 011111101111111111MMON1 KITCHEN SINK l 1 LAVATORY MIMI 11111111MMIMMINiniMiiiiiiMillilliii.111111MM _ _ I _ ROOF DRAIN ' SHOWER STALL [ � ' SERVICE / MOP SINK C _ � ... (.v .�. _.E ,i „f rmir TOILET ,_. _ ..... __ __... _. . _ __,.. , URINAL WASHING MACHINE CONNECTION I I - WATER HEATER ALL TYPES 1 1, /IT maimmis WATER PIPING We agnumni t , cm, _.. _. OTHER , I iamm......mm[MIimmaginimilloillmorlin all . .. _ liiiiiMEEME INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Li 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 i 1 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW J LICENSE # 12298 . SIGNATURE MP; i < JPJ CORPORATIONrn# 3281C PARTNERSHIP # LLC1# COMPANY NAME E.F. WINSLOW PLUMBING & HEATING 1 ADDRESS 8 REARDON CIRCLE R CITY SOUTH YARMOUTH STATE MA 1 ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 1 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM m. The Commonwealth of Massachusetts Department of Industrial Accidents -,-„6.,-- Office of Investigations 4 1 `k Lafayette City Center /Y� �:/ 2 Avenue de Lafayette, Boston,MA 02111-1750 ,, t` 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.r]�. 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.] 12.111 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' e the �i nsa�d penalties of perjury that the information provided above is true and correct. Signature: Y 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): 1,1=IBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I IgS CITY YARMOUTH MA DATE 'January 25,2022 I PERMIT# BLDP-22-004123 JOBSITE ADDRESS 11 COLLINGWOOD DR OWNER'S NAME AFRAME JAY Z G OWNER ADDRESS AFRAME MYRA B 27 BARRY RD WORCESTER MA 01609 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL CI RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT,© PLANS SUBMITTED:YES 0 NO 0 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 I 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 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# ILLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 18 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL I FAX CELL EMAIL IinspectionsWefwinslow.com 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t , _ � 5 CITY YARMOUTH (PORT) MA DATE i 1118122 PERMIT # f Z 2 `' I Z3 L JOBSITE ADDRESS 11 COLLINGWOOD DRIVE OWNER'S NAME : JAY AFRAME G _ OWNER ADDRESS SAME TEL 508-981-0401 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL f RESIDENTIAL "' PRINT CLEARLY NEW: I_ RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS-0 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 - INSURANCE COVERAGE .............. I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES . i NO ' I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND L( 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. _ ? ,0.4.41�.- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE #' 12298 SIGNATURE MP i MGF i JP L ...: JGF LPGI LJ CORPORATION i # i 3281C PARTNERSHIP # LLC # COMPANY NAME: E F WINSLOW PLUMBING & HEATING ADDRESS1 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM .... ... aaw,,w.ns,.3+.dwrX,.•w,in..... web'i.' -......tlA3.aiwik%':.•. .,,•, . J The Commonwealth of Massachusetts Department of Industrial Accidents , `' � ' Office of Investigations =r 4 > ! Lafayette City Center /l%^ 2 Avenue de Lafayette, Boston,MA 02111-1750 k -`,s�/`�i 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 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.❑ 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 ' e the ins and penalties of perjury that the information provided above is true and correct. ' / 12/01/2021 Signature: c Y 1 .'L.. 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.❑Board of Health 2.1=I Building Department 30 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 GAS FITTING WORK . �� � • Z2— CITY YARMOUTH(PORT) MA DATE 1/18/22 PERMIT# 123 G JOBSITE ADDRESS' 11 COLLINGWOOD DRIVE OWNER'S NAME JAY AFRAME OWNER ADDRESS SAME TEL 508-981-0401 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO � APPLIANCES 1 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO L 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 aVPPrtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � Y PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP MGF JP JGF LPGI CORPORATION # 3281C PARTNERSHIP '#' LLC D# COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM