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HomeMy WebLinkAboutBLDP & G-22-006946 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK vL CITY YARMOUTH MA DATE 6/1/22 PERMIT# BLDP-22-006946 JOBSITE ADDRESS 5 BURCH RD OWNER'S NAME MALASPINA EDMUND J(LIFE EST) y P OWNER ADDRESS P 0 BOX 7136 PROSPECT,CT 06712 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:❑ REPLACEMENT El PLANS SUBMITTED: YES NO❑ FIXTURFS • 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 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'1Q298 SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 18 REARDON CIR 8 REARDON CIR CITY ISYARMOUTH I STATE IMA ZIP 026641207 TEL FAX I I CELL I I EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El El FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH (SOUTH)�u x MA DATE 5/26/22 PERMIT # JOBSITE ADDRESS 5 BURCH ROAD OWNER'S NAME EDMUND MALSPINA POWNER ADDRESS SAME TELL 508-394 3154 i FAX . _ TYPE OR OCCUPANCY TYPE COMMERCIAL ill EDUCATIONAL „,,,,j RESIDENTIAL i , PRINT CLEARLY NEW: 1 i RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES . ' NOL FIXTURES -1 FLOOR-0 BSM 11/111 1.1:11111,11111111! 11111111111 NM INN INS CROSS CONNECTION DEVICE I L_____F-- r ' ' 1,111111!.. 1 i rill DEDICATED SPECIAL WASTE SYSTEM .... _ DEDICATED GAS/OIL/SAND SYSTEMI' III DEDICATED GREASE SYSTEMIli — rnE i i. DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM l l im I i 1 DISHWASHER �f 1 , _DRINKING FOUNTAIN ._ �_ Y11 ' FOOD DISPOSER l I' FLOOR /AREA DRAIN .. .�.._ r--- I i. .. INTERCEPTOR (INTERIOR) I KITCHEN SINK j_ LAVATORY NM i 1 ;' NEI l ROOF DRAIN IF h SHOWER ;_.. i i m mom SERVICE / O. TOILET ,,,. , , , :I !Illil_ _ , �I WASHING MACHINE • l._ _ 1 WATER HEATER ALL TYPES 1 I i , WATER PIPING s ' " ----111111111 1 ii,,,_ 1_.._ a , _ OTHER 1 1 L _ 1 '. lC MIMI INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES El NO L• 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 AGENT 111 , 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 lia : with II ertine pro' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C--, r .4.10, #4464, 10•6•...•'.. PLUMBER'S NAME STEPHEN WINSLOW !LICENSE # 12298 SIGNATURE MP � I JP CORPORATION i) #�3281C 'PARTNERSHIP # I LLC ... ;#, COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE ._ Y MA ZIP 02664 TEL [508-394-7778 _ 2, 1 EMAIL I S INSPECTION EFWINSLOW.COM , FAX 5Q8-394-8256 CELL N/A @ _.__.,._ _ ...�.__.„,...:...,._,,.. y _. The Commonwealth of Massachusetts Department of Industrial Accidents 9 y` '�--�� Office of Investigations i;l .r Lafayette City Center /11 2Avenue de Lafayette, Boston,MA 02111-1750 ""''� �� wwx.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.II] 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 state.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.❑ 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.❑ 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. I do hereby cer ' e the ins and penalties of perjury that the information provided above is true and correct. Signature: 7' '` ...�<^-- Date: 12/01/2021 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): 1.111Board of Health 2.0 Building Department 3.0 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 Vzsl CITY YARMOUTH MA DATE 'June 01,2022 I PERMIT# BLDP-22-006946 JOBSITE ADDRESS 5 BURCH RD OWNERS NAME 'MALASPINA EDMUND J(LIFE EST) G OWNER ADDRESS P 0 BOX 7136 PROSPECT CT 06712 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL El 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 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 0 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 I LICENSE# 112298 I SIGNATURE MP©MGF 0 JP 0 JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: 'STEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR.8 REARDON CIR CITY IS YARMOUTH I STATE MA ZIP 026641207 TEL FAX 1 'CELL I EMAIL 'inspections0.efwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El El FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _- CITY YARMOUTH (SOUTH) 1. MA DATE 5126122 PERMIT # JOBSITE ADDRESS` 5 BURCH ROAD OWNER'S NAME EDMUND MALSPINA GOWNER ADDRESS SAME TEL 508-394-3154 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIAL ✓ PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES ' NO APPLIANCES Z 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 rv...,.. . _ -- GRILLE INFRARED HEATER — LABORATORY COCKS _ MAKEUP AIR UNIT OVEN I POOL HEATER — ROOM / SPACE HEATER — ROOF TOP UNIT 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 ' NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1,' ` 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 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 b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc I a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws0 r ....4.. % . "pi.../IIL ,., . _ ., PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP i MGF JP A JGF ; LPGI f,,-.., , CORPORATION � �# 3281C PARTNERSHIP li� # LLC `--1# COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 „ TEL ` 508-394-7778 _ . 1 FAX 508-394-8256 t CELLI NIA EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts l rr1�s► Department of Industrial Accidents +' Office of Investigations ir�� = 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 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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4.ElWe are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.11I 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. I do hereby cer ' 7 I -the gizins and penalties of perjury that the information provided above is true and correct. Signature: Date: 12/01/2021 Y '` 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=IBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia