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Home My WebLink AboutBLDP-22-004361 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i-/ CITY YARMOUTH MA DATE 2/7/22 PERMIT# BLDP-22-004361 JOBSITE ADDRESS 58 LONG POND DR OWNER'S NAME BEACHWOOD INC P OWNER ADDRESS C/O ROBERT BURKE 800 GIFFORD ST EXT FALMOUTH,MA 02540-2952 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑ PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:El PLANS SUBMITTED: YES NO El FIXTURES • FLOORS-, RSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 2 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 OTHER 1 OTHER DESCRIPTION:sillcock 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 El OTHER TYPE OF INDEMNITY El BOND El 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 1a2298 SIGNATURE MP El JP 0 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 ri.3) e ---- - - ______ ‘,,,, ,z# CITY IYARMOUTH I MA DATE I211/21 JPERMT # 7-1 - i'13� I JOBSITE ADDRESS 158 LONG POND DR SOUTH YARMOUTH J OWNER'S NAME MORRIS OCONNOR & BLUTE FUNERAL I P _ OWNER ADDRESS SAME , I TEL 5083982121 FAX Min TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES Li NO® FIXTURES Z FLOOR-► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I! Imo.MR Wii CROSS CONNECTION DEVICE MI MI EMI ' ,IMMINE NIB ME 111111111111111111 1111111 NMI'`IMO DEDICATED SPECIAL WASTE SYSTEM u Ern nig;m. DEDICATED GAS/OIL/SAND SYSTEM NE En ing� m nig IMINEN. DEDICATED GREASE SYSTEM BIMCam; . INN MI iiIii, ,EMI DEDICATED GRAY WATER SYSTEMmg On J lam w 1 MOW mg um DEDICATED WATER RECYCLE SYSTEM . 1111111101111111111. ( ;. .. .7-1 DISHWASHER ------- _ Mu musa !im umno------im mu mg N. _ _ ._, DRINKING FOUNTAIN ' _ I. _�__ _ _ , FOOD DISPOSER : .i Wong --- . FLOOR /AREA DRAIN i MI MS 11•11 INTERCEPTOR (INTERIOR) WIF—MOIMI MIIII ' I1.1111' IIMMINOTO KITCHEN SINK LAVATORY . 111111111111 17— 111111M111001 ----, ROOF DRAIN _M_ �; �; j SHOWER STALLW IIIIIMIIIIIIII.ill MIMI, IIMMIEM _ SERVICE / MOP SINK EMI 11110111MAIIIIIIIIIIMMI MEi TOILETS M NNE URINAL L — 1111111Mtal NW intM MiliallaitillMlini WASHING MACHINE CONNECTION 11111.1111111111111111111 11111111111411111111111111111111 _OM WATER HEATER ALL TYPESti ,ou o mil' WATER PIPING r' MIIIIIIIIMMAIIIII.MMIIIIIimmeWitMN OTHER BACKFLOW PREVENTOR NMI' M _ �111111111011INIMMINIMINI SPIGOT —� I MME 1 �•�1 � MI . ilini Ti 1 — IMINIM MN INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES . NO J IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v OTHER TYPE OF INDEMNITY D 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 corn lia with II ertine pro''isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - PLUMBER'S NAME STEPHEN WINSLOW �SIGNATURE � .� �� LICENSE # l 122981 D— MP - JP LJ CORPORATION Ej# 3281C 1PARTNERSHIPD#, ; LLC®# NMI j COMPANY NAME E.F. WINSLOW PLUMBING & HEATING 1 ADDRESS 8 REARDON CIRCLE , CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 1508-394-7778 L FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts ii)=WI=-0 —..... Department of Industrial Accidents =.L 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: Business Type(required): 1.❑■ 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, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. 0 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]** 11.0Health 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 ter m e•the ins and penalties o_f perjun that the information provided above is true and correct. 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): 1❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia