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Home My WebLink AboutBLDP-21-005261 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK � CITY YARMOUTH ] MA DATE 3/15/21 PERMIT# BLDP-21-005261 ! JOBSITE ADDRESS 26 DANCING BROOK RD OWNER'S NAME CLARK FREDERICK TR P OWNER ADDRESS 'DANCING WILEY RLTY TRUST 14 WILEY RD BELMONT,MA 02478 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 El 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#2298 SIGNATURE MP El JP ❑ CORPORATION ❑# PARTNERSHIP El# LLC El# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com r see ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ FEESS PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =w� f=• CITYL Ya,(rrt�It/ .... ._....,.w .,�,,. -..._ , , ,..,.� ,...1 MA DATE Z jZ PERMIT # P_ 1-- 61 ''.P�=lam JOBSITE ADDRESS I2(0 bototc;%4 �(40A( Q' S Yo,ioNik I OWNER'S NAME Fier POWNER ADDRESS \ i \ e i g j 1✓1.961 1 NCI O Z -1 l fl TELESO 14 SCG. .W...,.. ...._,_ _FAX r_ , , TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ,_., RESIDENTIAL 1 PRINT _ CLEARLY NEW: I, . ..I RENOVATION: D REPLACEMENT: [ PLANS SUBMITTED: YES L NO FIXTURES -1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB f f r .1 - - _„____I11Milgel CROSS CONNECTION DEVICE i _ , { ; - DEDICATED SPECIAL WASTE SYSTEM ; DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM __ _ -__ : ` ___ _ _ wit tiniiimentlimIM DEDICATED WATER RECYCLE SYSTEM I--1 ®,r a I f DISHWASHER __ v A. ._______,!_ ___ _ -M011.111AIIIMMIR DRINKING FOUNTAIN -- . 1 ;I _ _ ____ -... _._ ______ _ __ .. .., FOOD DISPOSER f _ 1 „ -.� `�._ .4 FLOOR /AREA DRAIN I Il . . _ I __. . Y{ INTERCEPTOR (INTERIOR) _____ � � �. —_ KITCHEN SINK __IT'LAVATORY or__ I -- ., -- I . I - _ I i ROOF DRAININC __ " - - _ ' _-_ I ..__ i[ .. __ _ .' SHOVVER STALL _________ I_ I.- _ __I _6 _ I_._ I I..______1L :' 1.1 SERVICE / •' t _ __ _ __ -- ' ' _ I II_ - I -_ 1, . , VVASHING MACHINE CONNECTION "MIL - - ir—, IIMUM1-1110M-- — -: -- 11H- - 1 --If - '- WATER ' ' I ii i - . jujimimullinielmeminumnpulimit immiummiIiiiir • _ _ _..`. _ _ I -- __I - ice ®®j7� I _ .- . ___..__Ii .c -___._ _. -: ___ _ ___, _ _ _�____ 1_:S_.._1 _�e__IL -__.w+...L..___v__ --u_e _s, .Lw_� ,_._.__-._L_w-�, - -J es-=__--- INSURANCE COVERAGE: have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142, YES 0 NO W,_„I 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 L. 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 Cj AGENT LII 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..a a - 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 li. : with II ertine pro'ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • _) PLUMBER'S NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE - MP JP D CORPORATION Eil# 3281C PARTNERSHIP •.... I# _ z _T .:4 LLC L,_,__ # „, _ COMPANY NAME E.F. WINSLOW PLUMBING & HEX:I:I-NIG-1 ADDRESS 8 REARDON CIRCLE s CITY SOUTH YARMOUTH i STATE I MA I ZIP 102664 1 TEL 508-394-7778 rJ `� _ -v� FAX r508-394-8256 CELL CN/A 1 EMAIL INSPECTIONS@EFWINSLOW.COM 0 ‘bs The Commonwealth of Massachusetts Department of IndustrialAccidents q, h Office of Investigations Lafayette City Center .. r 2Avenue de Lafayette, Boston,MA 02111-1750 0. 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.rill 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.0 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 cer ' f the J zins and penalties of perjury that the information provided above is true and correct. Signature: Y 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.❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.El Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia