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HomeMy WebLinkAboutBLDP&G-22-004781 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ur2=: f, CITY YARMOUTH MA DATE 2/28/22 PERMIT# BLDP-22-004781 VI-t=f=-j JOBSITE ADDRESS 49 KATES PATH VILLAGE OWNER'S NAME THOMAS SPIROS J P OWNER ADDRESS THOMAS CAROLYN A 43 BRAY FARM ROAD YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: D RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ 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 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 12298 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$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �i„„w CITY YARMOUTH PORT _.. .__ MA DATE 12/21/22 _ PERMIT # _ JOBSITE ADDRESS 149 KATES PATH si OWNER'S NAME SPIROS THOMAS P mm OWNER ADDRESS ? SAME TELI 508-846-9076 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL....( EDUCATIONAL tr171 RESIDENTIAL . PRINT CLEARLY NEW: EJ RENOVATION: ' REPLACEMENT PLANS SUBMITTED: YES = = NO' FIXTURES -1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB i I __ 1-11---11 _.,., _...._,._....._ -11--- ..__ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ._. DEDICATED GAS/OIL/SAND SYSTEM 111.011111111111111.11111111011111.1111111.111111111 Man y DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM 111.11111111MMININNIMMint I- if I€ DEDICATED WATER RECYCLE SYSTEM m 1 i ov I E . , DISHWASHER 1 ,_= DRINKING FOUNTAIN ' 1 �: I 1 '` F _ FOOD DISPOSER _...�._ �1- 1_ .. . i W_ �. ., FLOOR 1 AREA DRAIN ' m a INTERCEPTOR (INTERIOR) r—' -71"mm „111111 - IIIIIIIIITOIFMIIIIII KITCHEN SINK LAVATORY € u r 11 INN ROOF DRAIN .11111111111111 UM SHOWER STALL 1.:: SERVICE / MOP SINK a - H _ INIIIIIIIMMIIIIIIIIIII TOILET . _ � �.. ,�.�. .� ,r.,.�..�_.-.. URINAL ii ._.. , .�.,.. , ..:. .. .l' .. s= ..._ ._ INN OM 11111111111111111 WASHING MACHINE CONNECTION INNIMINIMMILIMINIMINIMIMMMINIMMINIMMan WATER HEATER ALL TYPES 1 „ WATER PIPING 3 � r; jj1 I ii OTHER I mg T_Illi".11111111111,,, immaill ... INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO 1-1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 71 AGENT 1 , 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 and that all plumbing work and installations performed under the permit issued for this application will be in co Ii with II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. mm mm _ PLUMBER'S NAME STEP_, HEN WINSLOW LICENSE # 112298 SIGNATURE MP JP Li CORPORATIONS #[3281C JPARTNERSHIP # LLC LI# � COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ! ADDRESS 8 REARDON CIRCLE -----i] CITY SOUTH YARMOUTH I STATE MA I ZIP 02664 TEL 1508-394-7778 FAX 508-394-8256 CELL N/A EMAIL ETEOTIONS@EFWINSLOW COM The Commonwealth of Massachusetts Department of Industrial Accidents 9 _fi�'_ v Office of Investigations Lafayette City Center �= 2 Avenue 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: I Business Type(required): 1.[ii 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.111 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 ce ' 7 the phin sand penalties of perjury that the information provided above is true and correct. Signature: �' /�/4.' 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.DBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE February 28,2022 PERMIT# BLDP-22-004781 JOBSITE ADDRESS 49 KATES PATH VILLAGE OWNER'S NAME THOMAS SPIROS J G OWNER ADDRESS THOMAS CAROLYN A 43 BRAY FARM ROAD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0 FIXTURES 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/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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER 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-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP©MGF❑JP 0 JGF 0 LPG! 0 CORPORATION❑#f PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL insoections(7aefwinslow.com S310N M3IA32i NVId #IIWZl3d $ :33d ❑ ❑ 11112l3d 3H1 SV S3A2i3S NOI1VOIlddd SIHI oN SaA S310N N01103dSNI 1VNId AlN0 3sn NO103dSNI 2JOd 39Vd SIH1 S310N NOI103dSNI SVD H9f1im MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a �=,= CITY YARMOUTH PORT MA DATE' 2/21/22 PERMIT # L( � ,w:,,,,,,.� a,mc„c a; is a.:.aa�x;,�.,....,r„auo;...a.aw,e.,.r w...:aa,,,up.:a::aa.:sw.,,aw wN. nwm.»aw:.:.u\wva,.,.,4 .........„„-,..... •.. .. ... a� s m,,.wwywwwwr.,.�_w,.......,.,,..._.....,,.w,....w..w.........._�,.,.,.,,..,_..,..w,...ww..w....,m...v......r...,.,...-_,.._.�w..___....: JOBSITE ADDRESS' 49 KATIES PATH OWNER'S NAME SPIROS THOMAS G OWNER ADDRESS = SAME TEL FAX 508 846 9076 TYPE OR OCCUPANCY TYPE COMMERCIAL • EDUCATIONAL RESIDENTIAL Lk PRINT CLEARLY , NEW. RENOVATION. ,,, REPLACEMENT ' PLANS SUBMITTED: YES NO IL APPLIANCES 1 FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .�. BOOSTER ; CONVERSION BURNER a . . ,.. ..: , , aw,,..,,aaa .---:wwxt.�e.4.— COOK STOVE DIRECT VENT HEATER DRYER • „ FIREPLACE FRYOLATOR FURNACE GENERATOR - - GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT i itl . . ......,•.;<.....a,-',' ,tq.y,�n»., .. _ a�xaazacaazx<.:. OVEN ,,.._.._._ M.. ,. POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT _ .n, :St...,rt.:: , TEST _. __ .,,. UNIT HEATER UNVENTED ROOM HEATER WATER HEATER __.1....:.. OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Li,., I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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 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 complianc a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r ----, ......."--,— PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE a �:aau ww,n MP MGF JP __. I ,. ... JGF LPGI CORPORATION `# 3281C PARTNERSHIP L #L—. - LLC # G COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE ;. 4 _.,A duwvii�..,.... .. :a maaw..x....X,..,4A CITY SOUTH YARMOUTH j STATE I "` .. w. —.]TEL508-394-7778 eT- FAX 508-394-8256 1 CELL' NSA EMAIL INSPECTIONS a@EFWINSLOW.COM , s„,,„h. axa...aawxau w,:a Nbot xau,axAMx. .;a.,xx...,..*Ki;.Y.,,,a4N ,ww..S.',.,Nae.x.as..s. ;.';.,...5.m4,...,ax5ass..;,:..aca.,,<.ao1.ae5,.w.:, .«,..a.A61:40.31Y..a«:sx«:11.:xikAaWauwr;,xaav,,ww.wwa.,-.... t4M23.<.aeawa The Commonwealth of Massachusetts Department of Industrial Accidents 9=w Office of Investigations ;1 Lafayette City Center = -t` 2 Avenue 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 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.[1] We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.12 Other *Any applicant that checks box#I 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 ' el�the and penalties of perjury that the information provided above is true and correct. �F/ / 12/01/2021 Signature: Y ..AI ^ 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 3.1=I City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia