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HomeMy WebLinkAboutBLDP-22-006612 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK u '� a CITY YARMOUTH MA DATE 5/17/22 PERMIT# BLDP-22-006612 JOBSITE ADDRESS 939 ROUTE 6A UNIT D1 OWNER'S NAME HESLINGA STEVEN G TR P OWNER ADDRESS HESLINGA LYNN E TR 1649 HYANNIS RD BARNSTABLE,MA 02630-1433 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURFS • 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 WATER PIPING OTHER 1 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 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 1Q298 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH 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$ PERMITS PLAN REVIEW NOTES . \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ---7. 4,,,..-=-__; _ T.y..;.,- CITY YARMOUTHPORT I MA DATE 5/11/22 I PERMIT # -Z.-2._ (4, CI I L - -,7"4" ,t_.-p..-- -, JOBSITE ADDRESS 939 MAIN ST UNIT D-1 YARMOUTHPORT i OWNER'S NAME LYNN HESLINGA _____j P ___ OWNER ADDRESS 1643 HYANNIS RD BARNSTABLE MA 02630 ._..J TEL 5083629638 I FAX 1 - 1 TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL 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 J 13 14 BATHTUB - .. - CROSS CONNECTION DEVICE r-- DEDICATED SPECIAL WASTE SYSTEM OE 'm'I� DEDICATED GAS/OIL/SAND SYSTEM I , DEDICATED GREASE SYSTEM r._ DEDICATED GRAY WATER SYSTEM _AMC_ lIllr..n.lrllIllFIIIIIMIIIIIIWMIF DEDICATED WATER RECYCLE SYSTEM � iMMIIIIIMINFINIMIIIIIIMIF DISHWASHER 1111011 r 1 MN MN WIIIMMAMIN DRINKING FOUNTAIN ;ice um—mop= FOOD DISPOSER 11111MOMMIIIMMI lii 1 Iiii um NNW FLOOR !AREA DRAIN MUM. MrllIllNillg OM allitiing INTERCEPTOR (INTERIOR) III W KITCHEN SINK n LAVATORY illorilellimpluirincourilliillillialliallill.. ROOF DRAIN 11111111111111 . SHOWER STALL IIIIIIIIIIIIIIIIIIIIIIINIIIII11111I . SERVICE / MOP SINK t, TOILET URINAL a WASHING MACHINE CONNECTION Mr PIIIIFNIIFPIIIFPIIIIIIIIIIIFIIIIIIIMIIIMIIIIFIIIIIIUIIIIF WATER HEATER ALL TYPES WATER PIPING 1111111 F. OTHER 'BUILDINGDRAIN UPGRADE immiiimmummoilimpwiarairmwdridimmu arna Mai Pim am NEMER NMI MIIK-11111111111•111111111....iiill =OM MI �IL. . OW - ,:.,._WW� _ . .. 4 ,,_ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES[ NO 0 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. 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 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 cc . a with II ertine prqsiy,of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW ]LICENSE # 12298 SIGNATURE C MP , JP❑ CORPORATION ]# 3281C -]PARTNERSHIPED#r LLC # s �. e COMPANY NAME[E.F. WINSLOW PLUMBING & HEATING i ADDRESS ► 8 REARDON CIRCLE `'' CITY SOUTH YARMOUTH J STATE I MA 7 ZIP 02664 I TEL 08-394-7778 FAX 508-394-8256 I CELL rN/A EMAIL INSPECTIONS@EFWINSLOW.COM 0 r- � 1 The Commonwealth of Massachusetts Department of Industrial Accidents 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): 1.[II 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. - ❑ tion-profit [No workers' comp. insurance required] 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]** 11.111 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:01/01/2022 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 ce rny-ten the ins and penalties of perjury that the information provided above is true and correct. Signature: i "� -..-�/'�-�• 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): 1fBoard of Health 2.0 Building Department 3.1=1 City/Town Clerk 4.1:Licensing Board 51:Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia