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Home My WebLink AboutBLDP-21-005948 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 4/14/21 PERMIT# BLDP-21-005948 11 JOBSITE ADDRESS 6 HIGH GROVE RD OWNERS NAME TIGGES JOHN L P OWNER ADDRESS TIGGES ANTOINETTE M 122 WEBSTER ST NEEDHAM,MA 02494 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ 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❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY E 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 12298 I SIGNATURE MP ❑ JP ❑ CORPORATION ❑R 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 � CITY Y n/0,/}`L, MA DATE IJ/ij fZ( ; PERMIT# f •vfti r JOBSITE ADDRESS 6 Hi G�dJZ ICU S , `ili j. ei. , OWNER'S NAME 1 P I q d 1 TE . .. ,�.r �u -- FAX ,-_--•'-�i__,}., J OWNER ADDRESS lZ �. �J� ;� � � h • L 511�� 0 � `b� � F x TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL Li RESIDENTIAL PRINT CLEARLY NEW: D RENOVATION: El REPLACEMENT: 1' PLANS SUBMITTED: YES ...2. ..d NO[1] FIXTURES -1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB • ----------. .-___.-��- r_t-.._._._),��[-__•_: -''�� --- � -- - -- - � ---_ CROSS CONNECTION DEVICE . _ } DEDICATED SPECIAL WASTE SYSTEM I,-_--- JI ..._...IL -- --- !'i -.._ 1 DEDICATED GAS/OIL/SAND SYSTEM _ �. DEDICATED GREASE SYSTEM ? I: , Pill _T __ DEDICATED GRAY WATER SYSTEM -------1 ' = --_ - -_ •Mt WE____-_; 4..________, ', E., =-T. DEDICATED WATER RECYCLE SYSTEM ^`T � . DISHWASHER i r ' ,lr--------. ___ _ _ � � r� __ '.. .. �� ,�.�.� -.._.�_.��, �... Jam. �--...i - �.--------.� _._.- --- ,- ---- ------- .IIIW-- -- - _ DRINKING FOUNTAIN ( � �� FOOD DISPOSER _T Itz - - - - -:_ -- -- -- --1 I_ FLOOR/AREA DRAIN G _ INTERCEPTOR (INTERIOR) i [ _�_ ._1___ �.- ___.r'L..._ _ _ -:;_�T i - zVa_at= .,tix.,.4..1;�: ziYici.....�:� __... .— _ _ ___ _ KITCHEN SINK s • I__. lI _ ti l LAVATORY - - ' -:-- - '. - - ---.I _� ^, - - '` --� �-- � -. :_ is � .._- .w �'-- � .-�.=-- -_ ri:vas.. -°,.-y -- - ii ROOF DRAIN _ _ - = -- -_ 1: ... -•- -_Ja _- _- -- .. _ . -- SHOWER STALL SERVICE / MOP SINK i Vir j TOILET :_._-,_' ---,--- ----- --. 1 -- - Lr i .- -ilk - _:[__J IL- - URINAL i ' i ' I_._......_..__.I ..._. .._...__ .__-.-_� ... \Ic_ _ .-_-._-_.__.� t.-_... _. Y i ,I -.__--_I �ttiY.!/offiiii: .:____,re..l ___.---f1 WASHING MACHINE CONNECTION � _ WATER HEATER ALL TYPES WATER PIPING _ _.._._ _- �:--._ �__i____t -_ _1 ..__. . IL._:_... :----- - -_- ,__.._--- ,� - —_:� _ ---_ OTHER ...k,.. ._ r.�_,F-.c_. u..-�... .r._.,..,„...._- - Qt ,.�,...�_..-...,.�s��1LSSriii`SS61a os...; a:+lEC�r•�SwL., ... ..... , �I - r-sa� '� -��: -_„�:�.�r-..�_: - _--t-- ------� c------� - --� -- — -- ------ ---- - ----- -- -- —. — -- - {` 11 „________.,_,,' I___. _ . _IL_ ..1_ _ __I _ ___t_ . _.1. _ _:_l_lt__ ____A__..1. _ _ II _ 1 . .. . __._...__-._.. . __ 77 -- -- -- (- i i i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Ej 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 0 BOND 1, 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. 0 CHECK ONE ONLY: OWNER r' AGENT ri 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 -1 LICENSE # 12298 SIGNATURE MP _�_ JP .,_-i CORPORATION E # 32816 PARTNERSHIPD# LLC -,.,..'I# _......_.__:_.._.._._..._I COMPANY NAME LE.F. WINSLOW PLUMBING & HEATING ` 1 ADDRESS r8 REARDON CIRCLE T~ � CITY SOUTH YARMOUTH 'STATE [ MAJ ZIP [02664 I TEL J5394-7778 FAX r 08-394-8256 CELL IN/A �1 EMAIL INSPECTIONS@EFWINSLOW.COM �� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center } r 2Avenue 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): LEI I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. E 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]** 11.❑Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.E 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 • 7 the phAins�d penalties of perjury that the information provided above is true and correct. Signature: 7' 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.OBoard of Health 2.0 Building Department 3.E 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 u-:4'lph=d WO Z CITY L yekkiliv_4,. ., MA DATE I... , Z. PERMIT# r� JOBSITE ADDRESS 6 14;5 k £rove Rd 5. Yam/nod& ` OWNER'S NAME_Ann Ire 5 POWNER ADDRESS 41- tit t li_51-A.._ita CI . I :...PI,'I . - TELI5U%)611 0 1 1? f FAX I,_,__. TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL EJ RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:11 REPLACEMENT: / PLANS SUBMITTED: YES ri N0ri FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB G.. 1 I 1 CROSS CONNECTION DEVICE , l DEDICATED SPECIAL WASTE SYSTEM j .11_11 1- j[_ _ . W I I DEDICATED GASIOILISAND SYSTEM ; 1 NM11111 GREASE SYSTEM11111:' ��_ DEDICATED GRAY WATER SYSTEM _ _ _ ,, , ______ DEDICATED WATER RECYCLE SYSTEMMil at _ , I . _. J . DISHWASHER , ° ` DRINKING FOUNTAIN l � T_,_ �_ __. FOOD DISPOSER In. e _ FLOOR I AREA DRAIN , _I! _IL ____ 7r - ____1 — .----i----I, 11_,-1 --: --- -I. _ =_I INTERCEPTOR(INTERIOR) ,L_ —�'° _ . — ,t__^— '�I ---- i___J . I..-- -' KITCHEN SINK F -II 1', LAVATORY . �' 1, ROOF DRAIN SHOWER STALL L . : I_ ...-:) - a_ J ' _ . = 1 SERVICE I MOP SINK <__ 1I __ I 1 -T. - TOILET _I' _ _L_ __ URINAL .' - !' '. !I I 'I =_ ' —_—' I_ I WASHING MACHINE CONNECTION I_ __ l I, _—:r j y�1 i_ _ -- WATER HEATER ALL TYPES i` WATER PIPING I - - ' �1 . - ;. . - - au_ la OTHER I _ _ WIC___ WII j Wl IW IW INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES J NO Li IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D 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. 0 CHECK ONE ONLY: OWNER 0 AGENT [j 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 yertine proyisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f/ PLUMBER'S NAME I.STEPHEN WINSLOW LICENSE# 12298 SIGNATURE � MP JP LI CORPORATIONS# 3281C PARTNERSHIP# ILLCL..- # 1 I COMPANY NAME LE.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE rJ CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 — FAX 508-394-8256 CELL NIA _1 EMAIL INSPECTIONS@EFWINSLOW.COM .._ _1