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Home My WebLink AboutBLDP-22-004130 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK SN ArL- CITY YARMOUTH MA DATE 1/25/22 PERMIT# BLDP-22-004130 II JOBSITE ADDRESS 183 ACRES AVE OWNER'S NAME GARGALY CHARLES J P OWNER ADDRESS GARGALY THERESA B 52 BLAKESLEE RD WALLINGFORD,CT 06492-5245 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES CI NO❑ FIXTURFS • FLOORS—r 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❑ 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 112298 SIGNATURE MP El 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 ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES • r, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK tCITY YARMOUTH (WEST) 1 MA DATE 01/17/2022 I PERMIT # CZ — k 1 % d JOBSITE ADDRESS 33 ACRES AVE, W. YARMOUTH, MA 02673 1 OWNER'S NAMEICHARLES GARGALY _mm OWNER ADDRESS ;52 BLAKESLEE RD, WALLINGFORD, CT 06492 I TELI'203 317-0591 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL L, EDUCATIONAL El RESIDENTIAL y, PRINT CLEARLY NEW. RENOVATION: Li REPLACEMENT: PLANS SUBMITTED: YES Ej NOD FIXTURES 7 FLOOR--I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Mr BATHTUB iII ) i CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM �_:hl,_... 4M, IMMI Mil. -11111111111111110 DEDICATED GAS/OIL/SAND SYSTEM 1 9 ( ; f- ' .. DEDICATED GREASE SYSTEM ; 'PM iinii MIN NNW : DEDICATED GRAY WATER SYSTEM ME EMIMN FM 11111001111111[MMOIMIIIIIIIIIIIOMM DEDICATED WATER RECYCLE SYSTEM -I I 1 _ 1111101M11.1110.1111 DISHWASHER 11111111111111111111.1111111.1M1111111 MEMOMMI11111II Mt ; DRINKING FOUNTAIN I EMI IIIII ' FOOD DISPOSER ii.,,,..,,,.. FLOOR /AREA DRAIN 111111.11.M.1111 1 #NMI MI 11111111111 III.MOB IMO r= INTERCEPTOR (INTERIOR) 11111.11MIM III_J KITCHEN SINK I, - i LAVATORY .. MilI f_ I ROOF DRAIN IIIRIIMMIIIIIIIIMTMIIMIFNIRIMIIII 11111111.1111110111111Mt SHOWER STALL SERVICE / MOP SINK TOILET F URINAL F . ... .f----zi IIIIII WASHING MACHINE CONNECTION IM ISM " IMIIIMMIM 11111 IMIIININIIIIIIIIIIM WATER HEATER ALL TYPES 1 MB WATER PIPING i i t I _ :F_ _ ' II I OTHER i I I I II I I I I :111111111111.1111MMI I I I, INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES LA NO ri IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY , 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 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; pro'isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW HI LICENSE # 12298 __. ....._ .... ,.. .,w... ... w.. . y.,._. ..... SIGNATURE MP JP CORPORATION 71# 3281C PARTNERSHIP# LLC 0# COMPANY NAME E.F. WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDONnCIRCLE m„ CITY SOUTH YARMOUTH STATE MA ZIP 1à2664 TEL (5o8-37 _J i FAX 508-394-8256 CELL N/A I EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents `ry ` Office of Investigations `\ �- Lafayette City Center r? 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): 1.0 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.❑ We 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. #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 the ins and penalties of perjury that the information provided above is true and correct. 12/01/2021 Signature: ? —% -.-•"� 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 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia