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Home My WebLink AboutBLDP-23-006077 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK a - ire CITY YARMOUTH MA DATE 514/23 PERMIT# BLDP-23-006077 1-f,� JOBSITE ADDRESS 114 SULLIVAN RD OWNER'S NAME DUNN FREDERICK R P OWNER ADDRESS DECKER FAITH B 114 SULLIVAN ROAD WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL D PRINT CLEARLY NEW:El 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY 0 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 N2298 SIGNATURE MP El JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 TEL 5083947778 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 El ❑ FEES$ PERMIT# PLAN REVIEW NOTES w�_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK lliti- ____ 76C0f• 7-00 60CY77 �� CITY VEST YARMOUTH MA DATE 5/1/23 jPEif T JOBSITE ADDRESS 1114 SULLIVAN ROAD ' OWNER'S NAMEIKATHLEEN FARLEY R ,� , . OWNER ADDRESS SAME TEL=508-414 5675 FAX is Fm71 TYPE OR OCCUPANCY TYPE COMMERCIAL p EDUCATIONAL ., RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: I PLANS SUBMITTED: YES N0 FIXTURES -1 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 M 11 12 13 14 BATHTUB �- �..�. T.. m �.� A x i xl 4 .. .. CROSS CONNECTION DEVICE 1 " • DEDICATED SPECIAL WASTE SYSTEMmionsinetwouilmonnimmiiiiimit DEDICATED GAS/OIL/SAND SYSTEM Mit ^ DEDICATED GREASE SYSTEM `. DEDICATED GRAY WATER SYSTEMIII ^ DEDICATED WATER RECYCLE SYSTEM i DISHWASHER IIIIIMOMIIIIIIIIIIIIIIIIIIIIIMIIIIIIIIIIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII DRINKING FOUNTAIN FOOD DISPOSER IIIIIIIIIMIIIIIINIIEIIIIIIINIIIIIIIIIIIIIIIIIFI eilltIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIM FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) - KITCHEN SINK _ LAVATORY I_. ROOF DRAIN 11111111.11111111111111111111111111.11 -- IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIilMtaflli SHOWER STALL SERVICE / MOP SINKEll IIIIIIraillillIlrllIllirIIIIIIIIIIIIIIIIItilil TOILET � IIIIIIIIIIIIMIIIIMIIIIMIIIIIIIIEIIMINIIIIIIIIIIIIIIWIIIIIIIIIIIIIIIIIIIIFII . URINAL Mail , z WASHING MACHINE CONNECTION .. WATER HEATER ALL TYPES 1 L . WATER PIPING OTHER EMI IlliNillIllIllIllIllIllaIIIIIIMIIIIIIIIIIIIIIIIIMIIIIIIallt i'i 1111.1111111 -Mir ' -----'1111111111111111111iii .1 ' ' IIIIIIIIIIIIIIIIIIIIIIIIIii , INSURANCE COVERAGE: I have a current Iiabilitjnsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ICI NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v OTHER TYPE OF INDEMNITY ri 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 1_, AGENT SIGNATURE OF OWNER OR AGENT 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 corn lia with II ertine pro' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW LICENSE # i 12298 .: ._ ,1 SIGNATURE MP JP El CORPORATION Ei# 3281C PARTNERSHIP # LLC[IJ# [ w.. COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ' ADDRESS [iREARDONCUCLE CITY;SOUTH YARMOUTH i STATE MA I ZIP i 02664 TEL 1508-394-7778 �. L _ v FAX 508-394-8256 CELL N/A EMAIL ` INSPECTIONS@EFWINSLOW COM ______, IN The Commonwealth of Massachusetts ' Department of Industrial Accidents ai h —,f o Office of Investigations (7, >, Lafayette City Center #ji2 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 120 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. III 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 *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:23 COMMONWEALTH AVENUE City/State/Zip: CHESTNUT HILL, MA 02467 Policy#or Self-ins. Lic. #2019A Expiration Date: 01/01/2024 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requited 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. 01/01/2023 Signature: Y - .0 - 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): l.❑Board 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