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Home My WebLink AboutBLDP-22-004521 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 2/14/22 PERMIT# BLDP-22-004521 JOBSITE ADDRESS 366 LONG POND DR OWNER'S NAME FARAH CHRISTINE J D OWNER ADDRESS 366 LONG POND DR SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ 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 1 . 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 t2298 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 ❑ FEES S PERMITH • PLAN REVIEW NOTES . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK: ' 11-54- — CITY iYARMOUTH SOUTH MA DATE 02/11/2022 I PERMIT # 2" t JOBSITE ADDRESS 366 LONG POND DR, S YARMOUTH, MA 026 OWNER'S NAME'CHRISTINE FARAH OWNER ADDRESS #SAMEi TELj508 292-9844 FAX[ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL v PRINT CLEARLY NEW: RENOVATION I REPLACEMENT: PLANS SUBMITTED: YES L NO FIXTURES —1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ __a__:'... r. CROSS CONNECTION DEVICE . ' ' s 1 DEDICATED SPECIAL WASTE SYSTEM ' DEDICATED GAS/OIL/SAND SYSTEM 1 � 1 - l - I �. .. . .. DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM TI w..�._. � � DEDICATED WATER RECYCLE SYSTEM fIl = DISHWASHER I �. }(e DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) I 1-v_�....._..... 1 .__.._W._ . .,_ )I NM KITCHEN SINK LAVATORY I ROOF DRAIN SHOWER STALL ( i1 i SERVICE / MOP SINK ! f __ .. l _... . TOILET f URINAL WASHING MACHINE CONNECTION iiiii- PNII 11111111111111 1111111111111iallilli 111.1111111,11111111111liall —1 WATER HEATER ALL TYPES 1 I r « _ w � , ....;.:-M F ,...mm„ WATER PIPING . { . _ OTHER r [_ ' � : y _- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES , NO 1l IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ili., 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 knowledce and that all plumbing work and installations performed under the permit issued for this application will be in co lia with II ertine proisio2,of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW LICENSE # 12298 ! SIGNATURE MP , JP 0 CORPORATION ;# 3281C JPARTNERSHIPJ# LLC # COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS [iREARDON CIRCLE -------i CITY SOUTH YARMOUTH STATE r-----,TA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 1 CELL I N/A EMAIL ' INSPECTIONS@EFWINSLOW.COM ' The Commonwealth of Massachusetts fn �= Department of Industrial Accidents � Office of Investigations --�,�= " Lafayette City Center f .�•/-- AV 2 Avenue de Lafayette, Boston, MA 02111-1750 . A- - 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]** 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: 01/01/2023 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. Y Signature: 0 ,...A" 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❑Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.1:Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia