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Home My WebLink AboutBLDP-22-005688 #42 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ! CITY YARMOUTH MA DATE 4/5/22 PERMIT# BLDP-22-005688 tI JOBSITE ADDRESS 42544 WILFIN RD OWNERS NAME Lillian Ely P OWNER ADDRESS 01890-2251 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES ID NO El FIXTURES 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 WATER PIPING 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 El NO❑ 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 El OWNERS 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. PLUMBERS NAME Stephen Winslow LICENSE 112298 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# J 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 ❑ 0 FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK qj -/ 4-:41:117.,_ CITY !YARMOUTH I MA DATE [3/30/22 1 PERMIT # S � � JOBSITE ADDRESS 42 WILFIN RD S. YARMOUTH MA 02667 I OWNER'S NAME LILLIAN ELY 1 P OWNER ADDRESS 31 SUNSET RD HOLYOKE MA 01040 I TEL 4134781019 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL LI RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: , PLANS SUBMITTED: YES [j NOD FIXTURES 1 FLOOR—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 3 - IIIIII Ell Mill Milli CROSS CONNECTION DEVICE INN 111111 4 _ -. : I I I DEDICATED SPECIAL WASTE SYSTEM mu „E=T---" ' ,� , 1 __ # =iiiiiif--1t.= DEDICATED GAS/OIL/SAND SYSTEM i NE NEI MI INN M DEDICATED GREASE SYSTEM - DM IIMINTIIIIIIIII DEDICATED GRAY WATER SYSTEM __ I.I I - 1 _ ]I 0 --.Mr-1 DEDICATED WATER RECYCLE SYSTEM Es imi mom Imo an am DISHWASHER I - li is DRINKING FOUNTAIN 1.11 IMO all NM NS MI MN NEI MI INN FOOD DISPOSER IIIII _ . . NE ION MI 1111111.11111111 NM , I FLOOR 1 AREA DRAIN ! j �' INTERCEPTOR (INTERIOR) I I. . L lmil KITCHEN SINK L._�.,..-..-. LAVATORY .� _ --_ 1111.1 � .�. .�, • I yam,,. ROOF DRAIN SHOWER STALL 'i ME N Mil NMI INN SERVICE / MOP SINK j _, ,, TOILET _ ' _, 1 URINAL , tl II 0 -4- 1 . _ li It1 WASHING MACHINE CONNECTION =Q EN NMI NMEll NM MN NE NMI INN WATER HEATER ALL TYPES IIIIII NE elk UNE .,111111 1111111,0111B 111111W1111111 1111111=''MI WATER PIPING 1 L L_. --A M .NE 1 .. 1 OTHER1. li t li____+÷ _ !!!!1! -" L._._.__I___ _......iL_Ii.._.r..._..II.....r . L._I 1 L_J INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES I NO Q 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 e to the b t of my knowledge v and that all plumbing work and installations performed under the permit issued for this application will be in corn lia with II ertine prcAisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r -- PLUMBER'S NAME 1 STEPHEN WINSLOW LICENSE # 12298 SIGNATURE V (� � MP , JP CORPORATION , # 3281C PARTNERSHIP(# LLC[ #I__ r COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE L CITY SOUTH YARMOUTH 1 STATE $ MA ZIP LO .2664 — TEL 508-394-7778 FAX r508-394-8256 CELL N/A �� i EMAIL I INSPECTIONS@EFWINSLOW.COM J The Commonwealth of Massachusetts Department of Industrial Accidents -, a_ Office of Investigations _... ...14....... .. "ili ' Lafayette City Center 2 Avenue de Lafayette, Boston,MA 0211I-1750 -SS. 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): LIE I am a employer with 90 employees (full and/ 5. 0 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, a'ito,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. 0 Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.111Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *My 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 cer�t the ins and penalties of petjul:'that the information provided above is true and correct. �.pl�-� 01/02/2021 Signature: 0) Y 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): l f Board of Health 2.❑Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia