The URL can be used to link to this page

Home My WebLink AboutBLDP-22-003165 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 12/3/21 PERMIT# BLDP-22-003165 JOBSITE ADDRESS 183 SOUTH SHORE DR UNIT A2 OWNERS NAME OCONNELL MARK A P OWNER ADDRESS 43 DEER RUN BELCHERTOWN,MA 01007 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES El NO El FIXTURES 1 FLOORS RSM 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 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El BOND El OWNERS 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 at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Stephen Winslow LICENSE 1Q298 SIGNATURE MP ElJP ❑ 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-;-Q-147----=-1.- -e yr7..1I # CITY IA-blievni (, ebtrii) .. MA DATE 11767aga PERMIT # Z2 - 3 1(0 JOBSITE ADDRESS ( 3.., ...,,100/- 51/eze-42, ./(-/.4-4 OWNER'S NAMEI/fr;:9/040"‘c)X.i/tA-e.....44-- _ . . • P OWNER ADDRESS FO /2/4e<Aoge. /-171-S 1.-4/0/4- 49,4 TEL //.5 63/56-2 3 1FAX ,. _ „ j _ ,, _ . „ a 7g_. b., TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL El RESIDENTIALO# PRINT CLEARLY NEW: LI RENOVATION: Ij REPLACEMENT: 0 PLANS SUBMITTED: YES D NOD FIXTURES 1- FLOOR- BSM 1 2 3 4 5 6 7 8 I 9 10 11 12 13 14 BATHTUB j 1 II ' 1 0 1 II CROSS CONNECTION DEVICE 11 _1 DEDICATED SPECIAL WASTE SYSTEM j ______ . _ it 11 1 DEDICATED GAS/OIL/SAND SYSTEM j . if _ __ _ _ _ id i DEDICATED GREASE SYSTEM I DEDICATED GRAY WATER SYSTEM i -- - - 1 i DEDICATED WATER RECYCLE SYSTEM 1 , - — :1 _ DISHWASHER I ___ _ i ,1. __, .. . __ __ 1 t- DRINKING FOUNTAIN _1 -- -, 11 1 - - I--- -- ---' - ---- 1-- -- -' . - - FOOD DISPOSER I 1--- FLOOR/AREA DRAIN l I INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY 1 - - --- - - - iJ \1 ROOF DRAIN ,_. ., . . j i - . -_ I SHOWER STALL N") SERVICE / MOP SINK I _ _ _ 1 __ -7 I J 1 - - I I - , - i -- TOILET 1 . -__ __ 1 _ __ _ _ - - - .- _ -J- i URINAL I. . ! _ . . . . .. . ' _ _ . . WASHING MACHINE MACHINE CONNECTION j - -. 1-__....._ . _, ___ _____ _. ____ _____-_ i--,, -- -. --',[- --1-.- --- - - - -- t WATER HEATER ALL TYPES I - I ) 1 WATER PIPING i . 1( ..1 - J tJ i OTHER li....., , I„ 1 _ _ I I ----- I -- - _ __ _ 1 - I ,4,.....46.....- - i........ --14., - - INSURANCE COVERA GE: IN I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Ej NO n -N. IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW n LIABILITY INSURANCE POLICY ri, OTHER TYPE OF INDEMNITY fl BOND LT vo \crlOWNER'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 D AGENT El 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 st of my knowledge ,....1 and that all plumbing work and installations performed under the permit issued for this application will be in corn Ha with 11 ertine proyãsior3of the ..11' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE -..... MP JPD CORPORATIOND# 3281C PARTNERSHIPO#.11111111 LLCD#L__________I , COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations lit — Lafayette City Center ="Y. 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:SOl1TELYARM.OUTH,MA_02664--- one:508-394-7778 - -- --- Are you an employer?Check the appropriate box: Business Type(required): 1.0 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. 0 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 1Q.0 Manufacturing no employees. [No workers' comp.insurance required]** l 1 ❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.❑ 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 41. 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.Lie.#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 I the DIA for insurance coverage verification. I do hereby ce the 'us and penalties of perjury that the information provided above is true and correct. ' / 01/02/2021 Signature: Y -'` — 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): 1.0Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.ElLicensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia