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HomeMy WebLinkAboutBLDP&G-21-000627 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 8/11/20 PERMIT# BLDP-21-000627 JOBSITE ADDRESS 11 FAST BROOK RD OWNER'S NAME COLLINS WILLIAM P P OWNER ADDRESS LARGER CANDACE 163 SO BRANCH PKWY SPRINGFIELD,MA 01118 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO 0 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/OIUSAND 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0 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 12298 SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY SYARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com r ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r - 5 CITY _YARMOUTH 1 MA DATE 07/28/20 PERMIT # .- (.1)P- re 7:1L)- JOBSITE ADDRESS 11 FAST BROOK ROAD, WEST YARMOUTH i OWNER'S NAME LARGER, CANDICE OWNER ADDRESS I. TEL 413.636.8486 IFAXL TYPE OR OCCUPANCY TYPE COMMERCIAL - EDUCATIONAL RESIDENTIAL [' PRINT CLEARLY NEW: [ _ RENOVATION: ' „ REPLACEMENT: i v i PLANS SUBMITTED: YES 1 NO. v ,i FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB '. CROSS CONNECTION DEVICE _ _____-_r- 1 ______ __ . � ' iL- DEDICATED SPECIAL WASTE SYSTEM 3 1 1 r . DEDICATED GAS/OILJSAND SYSTEM I ( � i 1r I l µ ii [j t I DEDICATED GREASE SYSTEM ' 1 DED!CATED f l l('�T C!-1 GRAY A`i WATER n T n SYSTEM �i n T r if__ ,-_ =$� ,,,....�......11 _ ...., .... .-._....._..... _.. _ '—__ DEu!CA i Eu R i YYA I ER S I S I EM .. � _.. 1-,�,„.. _ ! .,..._. L .. . .. 1_ _�....�;,; DEDICATED WATER RECYCLE SYSTEM 'F— � DISHWASHER r I :' it1 DRINKING FOUNTAIN I I imis Iir: � _ .FOOD DISPOSER � ... ........_. FLOOR/AREA DRAIN -=- _ w A ._ _ . INTERCEPTOR (INTERIOR) �' _ n- ' �� KITCHEN SINK LAVATORY ! 1 £ rc - -- , ROOF DRAIN I il_ , t__. SHOWER STALL11 ; ll. I II SERVICE / MOP SINK 11 11 1.1-- 11— ,ro TOILET £ i, URINAL I ° WASHING MACHINE CONNECTION _ WATER HEATER ALl_ TYPES 1 v __. ..s: ... .. ` l .. .. WATER PIPING __.._ __ ��. � �1.— _._ � ' � ____}; OTHER �F _ _ . , , L F 1 ir F---- -1r- -1-----11- ir-tr-li - ' 1 ir— f W/O 529728 S40.00 3 _ INSURANCE COVERAGE: t ...._ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 14 . YES [] NO !F YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE 9Y CHECKING THE APPROPRIATE BOX BELOW AUG 0 6 2020 LIABILITY INSURANCE POLICY v i OTHER TYPE OF INDEMNITY ' BOND BUILDING DEPARTMENT OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required b Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 1-- AGENT [Q 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 perm t 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 LICENSE # 12298 1 SIGNATURE MPIv JP CORPORATION # 3281C IPARTNERSHIPLJ#L ' LLC7# COMPANY NAME[E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA I ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents _ Office of Investigations 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 90 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ 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. #1909A Expiration Date: 01/01/2021 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: Y '' .......1....-- Date: 01/02/2020 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 30 City/Town Clerk 4.11Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE Lugust 11,2020 DERMIT# BLDP-21-000627 JOBSITE ADDRESS 111 FAST BROOK RD DWNER'S NAME COLLINS WILLIAM P G OWNER ADDRESS LARGER CANDACE 163 SO BRANCH PKWY SPRINGFIELD MA 01118 tEL' TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES❑ NO❑ FIXTURES FLOORS—F 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 I 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITYD 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 _ICENSE# 12298 SIGNATURE MP©MGF❑JP JGF❑ LPG'❑ CORPORATION❑# PARTNERSHIP ❑# I.LC❑#� COMPANY NAME: 'STEPHEN A WINSLOW 'ADDRESS. 8 REARDON CIR, CITY IS YARMOUTH TATE MA 'IPI026641207 lIEL FAX jELLI— MAILlinspections@efvnnslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes N THIS APPLICATION SERVES AS THE PERMIT ❑ El FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK / CITY YARMOUTH 1 MA DATE 07/28/20 PERMIT # C -/ -er�d -.2.7 • JOBSITE ADDRESS 11 FAST BROOK ROAD, WEST YARMOUTH OWNER'S NAME LARGER, CANDICE OWNER ADDRESS TEL 413 636 8486 FAXaM TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ' RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEVIENT: 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 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER _ ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER W/O 529728 $40.00 INSURANCE COVERAGE ,_ rF r �• ' I have a current liability insurance policy or its substantial equivalent which meets the requirements of MG . R. 2 '4' I ' I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELO LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY L OIgi 06 2020 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage requir: d hyj _a-MU 1 ottheMEN1 Massachusetts General Laws, and that my signature on this permit application waives this requirement. By._ -- 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 accurat 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 compiianc:.*n+i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Y PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP MGF r JP JGF LPGI ' CORPORATION # r3281 C PARTNERSHIP #j LLC # COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH ] STATE MA !ZIP! 02664 TEL 508-394-7778 FAX1 508-394-8256 CELL N/A 1EMAIL1 INSPECTIONS@EFWINSLOW.COM . The Commonwealth of Massachusetts Department oflndustrialAccidents •• 971:--7' 't# Office of Investigations ':` = Lafayette City Center —' — f 2 Avenue de Lafayette, Boston, MA 02111-1750 '`c 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.El I am a employer with 90 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ 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. #1909A Expiration Date: 01/01/2021 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 • i the ins and penalties of perjury that the information provided above is true and correct. Signature: Y !^....— Date: 01/02/2020 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