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Home My WebLink AboutBLDP-22-003162 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 12/3/21 PERMIT# BLDP-22-003162 JOBSITE ADDRESS 8 SILVER LEAF LN OWNERS NAME Dave Shaugnessy P OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURFS FLOORS—, RPM 1 2 3 4 S 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 D NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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. PLUMBERS NAME Stephen Winslow LICENSE T2298 SIGNATURE MP ❑ JP 0 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 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1-willio=e r _ _.. 7 .1111iMi,_ CITY [YARMOUTH WEST MA DATE ;1112912021 PERMIT # I tu� `;c tiy` .. --- JOBSITE ADDRESS 8A & 8B SILVERLEAF LN, W. YARMOUTH, M OWNER'S NAMEDAVE SHAUGHNESSY 1 OWNER ADDRESS 7 BAYBERRY RD, NATICK, MA 01760 1 TEL (508)259-4973 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ___i EDUCATIONAL RESIDENTIAL El PRINT CLEARLY NEW: i RENOVATION v ' REPLACEMENT: 0 PLANS SUBMITTED: YES [ N0 fl FIXTURES Z FLOOR-0 BSM !„,„,,,p3 4 5 6 7 8 9 10 11 12 13 14 ', , BATHTUB CROSS CONNECTION DEVICE uniu : - I, DEDICATED SPECIAL WASTE SYSTEM IMININ NM INS 11111' _ NM Mal NM .__. DEDICATED GAS/OIL/SAND SYSTEM 111111 IMO,NUM1111111111111 T a _ [ 'L...®,.I,- I DEDICATED GREASE SYSTEM t :� 1,,.,, i..-i �:: _ t E .. , ,, DEDICATED GRAY WATER SYSTEM `.- _ ,.,.,,. Q, ME DEDICATED WATER RECYCLE SYSTEM r„- f tt ' 1 II DISHWASHER I ... '. DRINKING FOUNTAIN 'I_, .. 11111 FOOD DISPOSER i ... 111.11 FLOOR i INTERCEPTOR (INTERIOR) i-- . ii ■yj{ if KITCHEN SINK3 LAVATORY il ROOF - ' f §$! j - MIMI ... . ,_ WASHING MACHINE CONNECTION I IIIII— MINN - in MN MI 11111111Mallit WATER PIPING 11111111.1111.111111.111111111111.11.11111111 NM 1.1111111111iin MOM 11111 OTHER I INN Ea= 1111 __... 1111111111.911111111111 1 r 4 onI '_ s ..::::: I. .._ i 1 .. m.o. '',‘ iiii[--L, _. _f INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES , v i 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 , W 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 Ell AGENT I 1 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted o• 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 lia with II ertine pro' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LSTEPHEN WINSLOW LICENSE # 112298 SIGNATURE MP JP CORPORATION #r3281C IPARTNERSHIPLJ# JLLCLJ# COMPANY NAME E,F. WINSLOW PLUMBING & HEATING J ADDRESS 8 REARDON CIRCLE CITY€ SOUTH YARMOUTH STATE 1 MA 111 ZIP 02664 TEL [ 508-394-m8 I FAX 508-394-8256 CELL N/A EMAIL [lNsPEcTis@i [5w.COM The Commonwealth of Massachusetts a Department of Industrial Accidents +9 Office of Investigations Lafayette City Center , ". 2 Avenue de Lafayette, Boston, MA 02111-1750 'M 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. ❑ 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 10.111 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.] 12.111 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 ' e the ins and penalties of perjury that the information provided above is true and correct. 01/02/2021 Signature: 7' "' .......4.-- 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): 1.1:Board of Health 2.❑Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia