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HomeMy WebLinkAboutBLDP & G-23-000421 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 7/26/22 PERMIT# BLDP-23-000421 I JOBSITE ADDRESS 300 BUCK ISLAND RD UNIT 71 OWNERS NAME JAMOUZIAN SIMON P OWNER ADDRESS JAMOUZIAN MARY C 300 BUCK ISLAND RD APT 71 WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES NO El 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 El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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 an 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 at 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 112298 SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ISTEPHEN A WINSLOW I ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA I ZIP 026641207 I TEL I FAX CELL I 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 � _ CITY YARMOUTH (WEST) -I MA DATE 7/15/22 PERMIT # '11•- � ''1 JOBSITE ADDRESS F300 BUCK ISLAND ROAD UNIT 7- OWNER'S NAME; MARY JAMOUZIAN OWNER ADDRESS L SAME TEL 508-771-3212 FAX r TYPE OR OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL LI RESIDENTIAL ril PRINT CLEARLY NEW: tyU... RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Ej NO i FIXTURES -1 FLOOR--• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE V DEDICATED SPECIAL WASTE SYSTEM Ir DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ,,.............7-"if DEDICATED WATER RECYCLE SYSTEM .m. DISHWASHEK € DRINKING FOUNTAIN 1--- r----- isiinummuramisionsim11.1111.1111111.111111111111111111 FOOD DISPOSER FLOOR /AREA DRAIN IIMNIIIMIINIIIIIIIIWIIIIIIIIIMMISIMIHMIIIIIIIINIINIIIIIIMIIITIIIIIIIMIWJI INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL INHIIIMIIMIIIIIMIIIIMIIIIIIIIIIIIIIIIIIMTIIMIIIIIINMNIIIIIIIIINIIIIIIIM SERVICE / MOP SINKOWN e: i TOILET1111111111111111111111111.11 - URINAL F .. ,... c I_ . . _ �,_�.. R I :.. .: WASHING MACHINE CONNECTION 111111111.1111111111111111•MIMIIIIMMINIONWIliiiiillitillM WATER HEATER ALL TYPES 111111-111111111111111.11111111111111111111111111111111.111111111111111111111101.11111-111111111111111, INN WATER PIPING MilliiiiIMUIRE illMIII.1.nnusensnsmmm : OTHER l . . , IIIIIIIIIIiIIIIIIIIIIIIIIIIW ISMIN11.111W11111111111M1111111111.1111111111111111! INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES rd. NO ,,,, IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ° i 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 F 1 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 co Ii with II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME1STEPHENNSLOW - 7, r- LICENSE # 2298 SIGNATURE MP JP El CORPORATION E # 3281C PARTNERSHIP J# I LLC # M COMPANY NAME, E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE , r .... ....� ...- .._ ,.__. .W CITY SOUTH YARMOUTH . STATE MA I ZIP ,02664 I TEL 508-394-7778 FAX 508-394-8256 CELL 1 N/A EMAIL INSPECTIONS@EFWINSLOW COM _ a - . ^m The Commonwealth of Massachusetts Department of Industrial Accidents 9 .. 6.-4Office of Investigations k ,, ,. ;1 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.❑� I am a employer with 99 employees (full and/ 5. ❑ Retail or part-time).* 6. 0 Restaurant/Bar/Eatir .. ` ' ".• •t 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sal 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.❑ 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.] 12.1=1 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:01/01/2023 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. 1 do hereby cer ' �Re the ph�ins and penalties of perjury that the information provided above is true and correct. /,/(/ 12/01/2021 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): 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ; . CITY YARMOUTH MA DATE July 26,2022 PERMIT# BLDP-23-000421 "` JOBSITE ADDRESS 300 BUCK ISLAND RD UNIT 71 OWNERS NAME IJAMOUZIAN SIMON G OWNER ADDRESS IJAMOUZIAN MARY C 300 BUCK ISLAND RD APT 71 WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED:YES 0 NO 0 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 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. PLUMBER-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP©MGF❑JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME ISTEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL I FAX CELL EMAIL Iinspections(a?efwinslow.com S310N M31ARI NV1d #±IWZl3d $ :333 El ❑ 1111M3d 3H1 SV S3AHRS NOI1VO lddV SIHI oN saA S31ON NO1103dSNI 1VNld AlNO 3Sfl 210103dSNI Z10I 3OVd SIHl S310N NO1103dSNI SVO HJl02i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK WailE11/ -, i i MEO --CITY ! YARMOUTH (WEST) MA DATE 7/15/22 -.M PERMIT # Z3 4.) `I s JOBSITE ADDRESS; 300 BUCK ISLAND ROAD UNIT 7 OWNER'S NAME MARY JAMOUZIAN G : OWNER ADDRESS 1 SAME TEL 508-771-3212 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL N.j EDUCATIONAL IA RESIDENTIAL CLEARLY NEW: RENOVATION t.„x 1 REPLACEMENT: t„,,,v,j PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ ._ BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT T TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER.... - __ — INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Lij NO _ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY `. i 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 TIJ 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 accurat to the b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ` _.._ .._....:::._.:..::..:.........: .:........_...,..__.....,_._.__-__.„.....,......:........_.:,........._._.:...,._._.___. - y� `` ,1—...-- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 r SIGNATURE MP v MGF I,,, JP JGF LPG, ? i CORPORATION i # 3281C , PARTNERSHIP a , #1� i LLC # w : COMPANY NAME. E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE __ ,.. _.. :,a ::x:.mea� _._ .. _.. xnww exw xu�,4. CITY (.SOUTH YARMOUTH STATE MA 1 ZIP 02664 _ TEL 508-394-7778 FAX E08-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM ::: _ .. :... _.,.:. :",.�_a.;w:ra.x :,w-: xaw..xiaawu:�xaea. ;:,::•. The Commonwealth of Massachusetts Department of Industrial Accidents 9 l' 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.® I am a employer with 99 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.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *My 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:01/01/2023 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 ' ee the ins/and penalties of perjury that the information provided above is true and correct. Si nature: "'' `J'• Date: 12/01/2021 M-.'`' g 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): I.❑Board of Health 2.1=I Building Department 3.❑City/Town Clerk 4.0 Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: - www.mass.gov/dia