Loading...
HomeMy WebLinkAboutBLDP&G-22-003611 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,_ CITY YARMOUTH MA DATE 12/29/21 J PERMIT# BLDP-22-003611 t JOBSITE ADDRESS 17 MAPLE ST OWNERS NAME CHAPMAN ROBERT P OWNER ADDRESS 342 E 53RD ST APT 44 NEW YORK,NY 10022 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ FIXTURFS FLOORS—, RSM 1 , 2 3 4 S 6 7 8 9 10 11 17 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND 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❑ OWNERS 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'1R298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑it PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY SYARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK , I. _J CITY YARMOUTH (SOUTH) k MA DATE E 12/14/2021_ I PERMIT # -L.2 — 3 G. cr JOBSITE ADDRESS 17 MAPLE ST, S. YARMOUTH, MA 02664 I OWNER'S NAME[ROBERT F. CHAPMAN 1 r.. OWNER ADDRESS 342 E. 53RD ST, APT 4H, NEW YORK, NY 10022-5231 4; TEL f FAX TYPE OR OCCUPANCY TYPE COMMERCIAL L EDUCATIONAL '_ RESIDENTIAL PRINT CLEARLY NEW: ':.;, ,I RENOVATION REPLACEMENT: El PLANS SUBMITTED: YES NO-31 FIXTURES -1 FLOOR—* BSM III 2 4 5 6 7 8 9 10 11 12 13 14 BATHTUB .. . . .... ... .. CROSS CONNECTION DEVICE 11111 ; I111111 DEDICATED SPECIAL WASTE SYSTEM willillmum am am ma am m NM am NM MI Ell OM DEDICATED GASIOIUSAND SYSTEM NW IIIIMIIIMIIIIIIIIIIIIIFIIIIIFIIMFIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIFIIIIIIIIIIIFIIIIII DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM • 1111 DEDICATED WATER RECYCLE SYSTEM inummisiiiIIIMINEW. DISHWASHER Wiling � '�! 1 1 DRINKING FOUNTAIN IIIIIIIIMFIMIIIIIIIUIWIMFIIIIIIIIIIIIIIIIIIIIINIMmlim_ NUM rWiiiii FOOD DISPOSER ( _ I _ 1I . 1 MB WM r-- imii FLOOR I AREA DRAIN iM1111.11111110.1111 iiii FMIIIIIIIIBIIIIMIIIIIII/IIIIIIII.IIIIIIIIII_ INTERCEPTOR (INTERIOR) iiiiiiMIENI Mill.111.111111111 I i�1I I 1I____ h MUM KITCHEN SINK iiii.M MN 00.111111.1.1MIIMIIINTIMlisiiiiMINIIIIIMINE LAVATORY NM I _ .III I ® te _ IIMINIIIIIIIII ROOF DRAIN r- �,' 5 SHOWER STALL , a . T SERVICE I MOP SINK _,,_.., . -- _ 11111111111111M MN 1 NUMMI TOILET1— URINAL 1[- t11,5111 inn , i Mill MEM ._._.� WASHING MACHINE CONNECTION ��'MI 1 I 11111111.1111 WATER HEATER ALL TYPES =MOM IIIIIIIMIIOIOIIIIIIII MI 111111 WATER PIPING MI 111111 OTHER I .. MINI MIR.IIIIIIII IIIIII MEI rai 11111 IIIIII ... II I MI I....... I.... 1 I 1 I I 11111.11MIMMINIMMIM INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO ri IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej 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 _, 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 to 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 pro' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER'S NAME STEPHEN WINSLOW .. .. ........ . LICENSE # 12298 SIGNATURE MPI JP El CORPORATION ,,# 3281C ]PARTNERSHIPD#I ] LLCLJ# _ 1 COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE m CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL [ 08-394-7778 1 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM ..�` The Commonwealth of Massachusetts - _ Department of Industrial Accidents 11-�J1--=,:' 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]** 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 *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 of perjury that the information provided above is true and correct Signature: ` T 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.❑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 CITY YARMOUTH(SOUTH) MA DATE 12/1412021 PERMIT# Z - JOBSITE ADDRESS 117 MAPLE ST,S YARMOUTH,MA 02664 OWNER'S NAME :ROBERT F.CHAPMAN OWNER ADDRESS 342 E.53RD ST,APT 4H,NEW YORK NY 10022-5231 I TELj212-687 1234- IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL L.1 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 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 I„ 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 STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP E MGF JP JGF LPGI. CORPORATION _# 3281C PARTNERSHIPLJ# LLC LJ# 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK P "V CITY YARMOUTH MA DATE 'December 29,2021 PERMIT# BLDP-22-003611 JOBSITE ADDRESS 17 MAPLE ST OWNER'S NAME CHAPMAN ROBERT G OWNER ADDRESS 342 E 53RD ST APT 44 NEW YORK NY 10022 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El 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 INDEMN ITY❑ BOND ❑ OWNERS 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 E 12298 SIGNATURE MP©MGF❑JP 0 JGF 0 LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(Sa.efwinslow.com