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Home My WebLink AboutBLDP-23-000422 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK s. CITY YARMOUTH MA DATE 7/26/22 PERMIT# BLDP-23-000422 JOBSITE ADDRESS 15 DEVONSHIRE LN OWNER'S NAME Leah King P OWNER ADDRESS 15 DEVONSHIRE LN YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW:0 RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES El NO❑ FIXTURES Fl OORS—. 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 WATER PIPING _ OTHER 1 OTHER DESCRIPTION:outdoor shower INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ 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❑ 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 W298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW I ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA I ZIP 026641207 TEL FAX I 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 4, i CITY YARMOUTH 1 MA DATE ! 7/19/22 1 PERMIT # Z 3 — C'' I, 4 Z— JOBSITE ADDRESS 15 DEVONSHIRE LN YARMOUTHPORT I OWNER'S NAME LEAH KINGMAN POWNER ADDRESS SAME TEL[7327789253 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL RESIDENTIAL "1 PRINT CLEARLY NEW: RENOVATION: I i REPLACEMENT: i PLANS SUBMITTED: YES 0 NOrl FIXTURES -1 FLOOR--► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ -.„___jI 1____ . CROSS CONNECTION DEVICE 1---- -II i; .._ � '� {- . DEDICATED SPECIAL WASTE SYSTEM I- --i -ow , ---t 4._ . _ J DEDICATED GAS/OIL/SAND SYSTEM _.,____ _ 7-11—T-F—__ -DEDICATED GREASE SYSTEM s �' i DEDICATED GRAY WATER SYSTEM _- I. f DEDICATED WATER RECYCLE SYSTEM [ _ -INN -- in — _ DISHWASHER F DRINKING FOUNTAIN _..xx - it -=�.� �,-. I t - FOOD DISPOSER L _ (I IL _ —'' _J! FLOOR / AREA DRAIN IL. r _ INTERCEPTOR (INTERIOR) L..L_ KITCHEN SINK [-- a.. EMIR -il ' ll LAVATORY _ _ I I _ ROOF DRAIN SHOWER STALL 'T- , —II- IC- - 1 L . SERVICE / MOP SINK : _ IIIIIII J l._.. �j ,i___ .-_1 i I TOILET M 11111111111111111111111111 URINAL 11111111111111111111111111110111111 IMIIIIIIIIIIIIIIII IIIIII Mill. WASHING MACHINE CONNECTION '1 1111111- 11 IIIMMIIMMEM----M111 MI MIN MINI WATER HEATER ALL TYPES iiiiiiiMillIMMIIIIIIIIMiiii MIS WATER PIPING .� i h M 111111 OTHERJOUTSIDE SHOWER `� 1 .___.t �; IMO IIIIII MIll INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES L'j NO r 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 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 b st of my knowledge ,.#p; 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. PLUMBER'S NAME STEPHEN WINSLOW I LICENSE # 17122-98 1 SIGNATURE c_ MP i JP CORPORATION # 3281C PARTNERSHIP # LLCL#r 0 s COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY' SOUTH YARMOUTH STATE MA ZIP 02664 i TEL F508-394-7778 FAX I 508-394-8256 J CELL N/A ' EMAIL INSPECTIONS@EFWINSLOW.COM I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Lafayette City Center 2Avenue 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 employe, with 90 employees(fall mid/ 5r ❑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.] 12.0 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 ce ee the ins and penalties of perjury that the information provided above is true and correct. Signature: ��""' 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): 1.1=1Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia