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BLDP-21-004681 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK , CITY YARMOUTH MA DATE 2/18/21 ] PERMIT# BLDP-21-004681 ir< � JOBSITE ADDRESS 21 LUCERNE DR OWNERS NAME HAYES MICHAEL K P OWNER ADDRESS HAYES SHARI L 21 LUCERNE ST YARMOUTH PORT,MA 02675-2120 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 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❑ 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 1298 SIGNATURE MP ❑ JP ❑ 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 r _ --m$ a —�'� CITY ! YARMOUTH _ _ .. ._ MA DATE 02/11/21 PERMIT # 6 L D - 2 ( °° CI 644 JOBSITE ADDRESS 21 LUCERNE DRIVE, YARMOUTHPORT j OWNER'S NAME HAYES, MICHAEL pOWNER ADDRESS TEL�0_ .737 7618 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 1i RESIDENTIAL PRINT CLEARLY NEW: RENOVATION REPLACEMENT: PLANS SUBMITTED: YES NO, i_ FIXTURES - FLOOR—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ . .. 1 11— CROSS CONNECTION DEVICE _.. ..._ _a . . u DEDICATED SPECIAL WASTE SYSTEM :, ., . :: _ v.__ ,.r.�e�_ I� . . i.,._�__ , . r. �mm ia a DEDICATED GAS/OIL/SAND SYSTEM ... � µ __ m.,.. ' 1011. DEDICATED GREASE SYSTEM i DEDICATED GRAY WATER SYSTEM _ , ..__,I, `1 DEDICATED WATER RECYCLE SYSTEM 11 F � �. DISHWASHER ' —r I 4 11-1 DRINKING FOUNTAIN Y r_._W M _..... .. ,......... . �...._: . . .. . .__.. FOOD DISPOSER i . . FLOOR l AREA DRAIN IL INTERCEPTOR (INTERIOR) Y� [ _ A L __,} KITCHEN SINKle �.dil 9 i I LAVATORY 13 a ._ , t _____A ii j , ROOF DRAIN SHOWER STALL . �: �;i : SERVICE 1 MOP SINK 1._ 1 ] ,i s� I TOILET r°_ T. . i i URINAL I I ,l gl_ WASHING MACHINE CONNECTION i ! _,.. _.__1 WATER HEATER ALL TYPES ter _ _._ 1 __� V 1 �.m I! WATER PIPING I -----': ';' OTHER 11 IIjr- _ 1 f e k_ I IWIO 544900 $40.00 7 � I C 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 , i 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 w.._.1 AGENT 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 lia : with II ertine pro)4isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW _________i LICENSE # 12298 SIGNATURE MP; i JP CORPORATION ;# 3281C PARTNERSHIP # LLC7 COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE r MA ZIP 02664 TEL j 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL [ SPECTRNS@EF\MNSLOW COM �( The Commonwealth of Massachusetts Department of Industrial Accidents R `' Office of Investigations I Lafayette City Center (1/4,__ ._ /' 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): 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. El Non-profit 3.❑ We are a corporation and its officers have exercised 9. E Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ 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.] 12.111 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 ' e the ins/and penalties of perjury that the information provided above is true and correct. Signature: �' '` -.A-r 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 2.1=I Building Department 3.0 City/Town Clerk 4.111Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Ei! CITY YARMOUTH MA DATE February 18,2021 PERMIT# BLDP-21-004681 JOBSITE ADDRESS 21 LUCERNE DR OWNER'S NAME HAYES MICHAEL K G OWNER ADDRESS HAYES SHARI L 21 LUCERNE ST YARMOUTH PORT MA 02675-2120 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 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 ❑ 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 ❑ JP❑ JGF❑ 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(a,efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �� r- ! , CITY YARMOUTH MA DATE 02/11/21 PERMIT# l 0 C9 — 1 -v Gti CI91 JOBSITE ADDRESS 21 LUCERNE DRIVE,YARMOUTHPORT OWNER'S NAME HAYES, MICHAEL GOWNER ADDRESS TEL 508.737.7618 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL 1 PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES` NO APPLIANCES Z FLOORS—I 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 WIO 544900$40.00 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE I NDEIVINITY 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 thasac all tts State work and installations performed of the hethe permit issued for this application will be in complianc P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Y PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP ' 'x MGF JP JGF LPG' CORPORATION # 3281C PARTNERSHIP —7#1 I LLC COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA-1 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 i,1.'"' CITY YARMOUTH i MA DATE 02/11/21 PERMIT # L 0 v — Z 4 - c0 6t! LI9/ JOBSITE ADDRESS 21 LUCERNE DRIVE, YARMOUTHPORT OWNER'S NAME HAYES, MICHAEL GOWNER ADDRESS _ TEL 508.737.7618 FAX _,:,._. „ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL [] RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z 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 �_ - _ ag MO 544900 $40.00 � � � INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 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 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 compliancove a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 0 r ' ...1...51,45.5..- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 I SIGNATURE MP MGF JP 11 JGF Li LPGI CORPORATION i # 3281C PARTNERSHIP D# 1 LLC 0# . COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY LSOUTH YARMOUTH I STATE MA ZIP 02664 TEL 508-394-7778 FAX[508-394-8256 CELL N/A :.EMAIL; INSPECTIONS@EFWINSLOW.COM I