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HomeMy WebLinkAboutBLDP&G-22-006053 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _! CITY YARMOUTH MA DATE 4/21/22 PERMIT# BLDP-22-006053 'f JOBSITE ADDRESS 36 PINE GROVE RD OWNER'S NAME NEILS VICTORIA A P OWNER ADDRESS PERELLA LORI A 68 JEFFREY LN WEST SPRINGFIELD,MA 01089-4476 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ 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 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 El NO El 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 12298 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY IS 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 w y , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK W I ti_._`, CITY [YARMOUTH (SOUTH) MA DATE 4/11/22IPERMIT # # : ,.,...,.....m......,......w...... ._.....,.......m......,.._..,.,.. .....m g JOBSITE ADDRESS t 36 PINE GROVE ROAD _:1OWNER'S NAME' VICTORIA NEILS POWNER ADDRESS i SAME...... ____ _ ..__ __ , _ . _.__ . ._.._ , _.•. . : i TEL 508-394 7478 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL n EDUCATIONAL [... RESIDENTIAL ril PRINT _w_„ CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOJ FIXTURES -. FLOOR--► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM .. 3 ... NMIt DEDICATED GAS/OIL/SAND SYSTEMM , _,_ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I 1 ._ _ -- &a,,. „• DEDICATED WATER RECYCLE SYSTEM : I DISHWASHER 0 .. . .. ,:w.. .. DRINKING FOUNTAIN I_, ...._ ___.W .._.. . I FOOD DISPOSER i _ € p FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) 1- KITCHEN SINK f I LAVATORY _ I I i k.... _ a ROOF DRAIN _ ��� _ ,_ ;:-;. . � ..�— ' SHOWER STALL :1"--11--11_. . 1 I$ .... . SERVICE I MOP SINK g? f I ?L I' 3 TOILET � URINAL i -Is 1, i € a WASHING MACHINE CONNECTION I ' 9 WATER HEATER ALL TYPES 1 4 an - WATER PIPING_......._._._._ .___ . ... .__,. .. . ...... ,. . OTHER [ '1 —11 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO rii IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' OTHER TYPE OF iNDEMNI T Y BOND , a 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 ,f 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. T PLUMBER'S NAME STEPHEN WINSLOW , 1LICENSE # 12298 - SIGNATURE MP i JP I i CORPORATION # 3281C PARTNERSHIP # LLCM--# COMPANY NAME E.F. WINSLOW PLUMBING & HEATING 1 ADDRESS 8 REARDON CIRCLE CITY i SOUTH YARMOUTH STATE [-iTA-1 ZIP 02664 TEL 508 394 7778 FAX 508 394 8256 1 CELL N/A EMAIL INSPECTIONS@EFWINSLOW COM The Commonwealth of Massachusetts Department of Industrial Accidents 9 'Y ,' Office of Investigations w Lafayette City Center /� 2Avenue de Lafayette, ti f= 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): 1.41 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,etL.) 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.❑ We are a non-profit organization, staffed by volunteers, 11.0 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. #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 ' e the ins and penalties of perjury that the information provided above is true and correct. Signature: Y - -p!^-" 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 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,r etL • CITY YARMOUTH SOUTH MA DATE 4/11/22 PERMIT# t, -- LI 3 JOBSITE ADDRESS 36 PINE GROVE ROAD OWNER'S NAME VICTORIA NEILS OWNER ADDRESS SAME TEL 508-394-7478 FAX[ j TYPE OR OCCUPANCY TYPE COMMERCIAL j EDUCATIONAL ..., RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES-1 FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i. 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I NO 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 n a PP 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 L.! MGF JP ', JGF LPG'?..3 CORPORATION # 3281C PARTNERSHIP #r LLC # COMPANY NAME:IE.F.WINSLOW PLUMBING&HEATING ADDRESS REARDON CIRCLE CITY SOUTH YARMOUTH STATE 1 MA ZIP€02664 TEL 508-394 7778 • FAX508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents '= tM Office of Investigations Lafayette City Center 1 2 Avenue de Lafayette, Boston,MA 02111-1750 Nig I 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.0 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-'�}y-tmm��th�Arns��nd-penalties of perjury that the information provided above is true and correct. Signature: Y 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 30 City/Town Clerk 4.ElLicensing Board 50 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 'April 21,2022 I PERMIT# BLDP-22-006053 I JOBSITE ADDRESS 36 PINE GROVE RD OWNER'S NAME NEILS VICTORIA A G OWNER ADDRESS PERELLA LORI A 68 JEFFREY LN WEST SPRINGFIELD MA 01089-4476 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES❑ 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 LABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY El 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❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. l8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL I I EMAIL inspectionsRefwinslow.com S310N M31A3H Ndld #1IW213d $:33d ❑ ❑ 11W2I3d 3H1 SV SSAH.S NOliV011dd`d SIH1 oN seA S31ON NO1103dSNI 1VNId AlNO 3Sf1210103dSNI 2IOd 3OVd SIHI S31ON NOI103dSNI SVO HOfO21