The URL can be used to link to this page

Home My WebLink AboutBLDP-21-002063 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Tim(,3_ CITY YARMOUTH MA DATE 1:10119120 PERMIT# BLDP-21-002063 rf ' JOBSITE ADDRESS 300 BUCK ISLAND RD UNIT 7E OWNER'S NAME WILLOUGHBY NANCY L TRS P OWNER ADDRESS DIBIASO JASON 1020 MERIDIAN AVE #508 MIAMI BEACH,FL 33139 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES a 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 0 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. PLUMBER'S NAME Stephen Winslow LICENSE 16298 SIGNATURE MP ❑ JP ❑ 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 PERMIT ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 2P-ai- 60-9‘06 3 '' CITY , Ygrm /V', ._ T . , MA DATE (Q j 1�� PERMIT# �L JOBSITE ADDRESS 360 IkI u0 _ ' al i+ ? C W OWNER'S NAME R)o( 4_, b r 6)-ol / � i� . e t�wr�v In � � FAx OWNER ADDRESS C kh a.�____-r-�-----� __ __.-- - TEL 30 y (2 c, 3 �.5 ,__,_-...._.___r TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIO AL 0 RESIDENTIAL PRINT CLEARLY NEW: EJ RENOVATION:Li REPLACEMENT: PLANS SUBMITTED: YES J NO _ FIXTURES 7. FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ _ ._ I- I - -. 1._._ ___II, _ --i l _- - _'II—_ --- ;- - L_. - - - CROSS CONNECTION DEVICE E - - unaliiiiMIUMNIIIM DEDICATED SPECIAL WASTE SYSTEM „.„,,,,F.-. DEDICATED GAS/OIL/SAND SYSTEM rippping... . I I ? um I _. DEDICATED GREASE SYSTEM I___— 1111111.11111.111111111111111111111111111111111111111111111111111111111111111111 DEDICATED GRAY WATER SYSTEM 'rDEDICATED WATER RECYCLE SYSTEM �^ r_ , rirl 1M DISHWASHER u_ ._ .._ . _ 1- -- ; 1 ',1 - L11111111111111 DRINKING FOUNTAIN IIIMIIIIIIIIIIIIIIIMI.__=- ,_.__ iL I l ._ .11�_i��,� IW- . M FOOD DISPOSER � [� -1 1 Willmi IW FLOOR 1 AREA DRAIN I INTERCEPTOR (INTERIOR) alei _ _ v_ _ ___ Jr.._ , _, .._._ _ _ KITCHEN SINK UNIPLEMI---E,-. ----- - L.„.ElriIllmIIFIIIIIIIIIIIIIIIIIIIIIII LAVATORY i lin ROOF DRAIN SHOWER STALL ilitE=INIM NI ___ -- aiiilmill-. -- *IF*mitlust SERVICE / MOP SINK ___ I li I[. L_I I TOILET FM MN MI MIL NM uniMI muiliaM1 ma NM SIN NM . IN URINAL MJIIIIIIIIII _ iIIIIIIII _ I WASHING MACHINE CONNECTION _--- ._ ! li igium[Wwilill WATER HEATER ALL TYPES7 it _ I` .MB i I - WATER PIPING „ _ S ' U .I N_sin OTHER _________ _ MP i, _i 11 - I �I !1 I I_ i, INSURANCE COVERAGE: I have a current Iiabilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Ld NO L. 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 P1 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. O CHECK ONE ONLY: OWNER I AGENT 12 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 to to the best of my knowledge &' and that all plumbing work and installations performed under the permit issued for this application will be in co Ii wit rertinerr.Risioof the Masschusetts State Plumbing Code and Chapter 142 of the General Laws. ? *. ,.{44' =- PLUMBER'S NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE 1 MPO JP[J CORPORATIONO# 3281C PARTNERSHIP®# �. .. _ .�I LLCL# ._ ._r_._.. c...) 4— COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS L8. 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 vr�a 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): 1.0 I am a employer with 90 employees(full and/ 5. ❑Retail 2.❑ or part-time).* 6. ❑Restaurant/Bar/Eating Establishment I am a sole proprietor or partnership and have no 7 El 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 no employees. [No workers' comp.insurance required]** 10.❑Manufacturing 4.ElWe 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: City/State/Zip: Policy#or Self-ins.Lic.#1909A 01/01/2021 Attach a copy of the workers'compensation policy declaration page(showing the pol cy 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 ' er the ins and penalties of perjury that the information provided above is true and correct. Signature: /Y 01/02/2020 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 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: