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HomeMy WebLinkAboutBLDP&G-22-003072 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK yr, CITY YARMOUTH MA DATE 11/30/21 PERMIT# BLDP-22-003072 JOBSITE ADDRESS 162 PLEASANT ST OWNER'S NAME ANSCHUTZ MARK S TRS P OWNER ADDRESS ANSCHUTZ REVOCABLE TRUST 162 PLEASANT ST SOUTH YARMOUTH,MA TEL 02664 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES i FLOORS—a RAM 1 2 3 4 5 6 7 8 9 10 11 17 3 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❑ 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 t2298 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 BST FEES S PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY [YARMOUTH SOUTH MA DATE 11/23/2021 PERMIT # JOBSITE ADDRESS [162 PLEASANT ST, S YARMOUTH, MA 026641 OWNER'S NAME MARK ANSCHUTZ POWNER ADDRESS SAME j TEL, 508 398-3488 FAX [ _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ._� :.t RESIDENTIAL _''] PRINT CLEARLY NEW: ; ` RENOVATION L REPLACEMENT: mm�_J PLANS SUBMITTED: YES ,.,._ NO FIXTURES Z FLOOR—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB i` CROSS CONNECTION DEVICE _ DEDICATED SPECIAL WASTE SYSTEM 1 ..,. ..._ DEDICATED GASIOIUSAND SYSTEM _ DEDICATED GREASE SYSTEM INS Nal MI 1111.111111111111MONIE 't _ 11111111111111115 DEDICATED GRAY WATER SYSTEM 1111111W1111111111N1101111111111111111111110.11001111111111111111111111111111111111 DEDICATED WA1 ER RECYCLE SYSTEM IS l i. m. DISHWASHER I1111111 I-1- F—iiiii _ I— !MINIM DRINKING FOUNTAIN r- FOOD DISPOSER , ___. r- j FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) . M ' KITCHEN SINK _— , -- 11111111 �. f LAVATORY IMIIIIIIMMIlliii I _ im ROOF DRAIN SHOWER STALL Is �. - - - SERVICE / MOP SINK 1 I` TOILET r r..__ URINAL ,,---1 I �. WASHING MACHINE CONNECTION T. It I; !) a WATER HEATER ALL TYPES I� „ __ -mm _ r li WATER PIPING .. - riff1i1rar,.. r.5 ____. __ I �'��� i OTHER , .v..� . _ _. ,... _ ,,2<,s- wry -x�,�<... � __ .r v � . � .. ...._..__ .I so . _.. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ! vi NO .:_i IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND p,......-.: 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 truer 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 co lia with II ertine pro' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW .__ _...._ , LICENSE # 112298 ._ SIGNATURE _ MP JP �] CORPORATION „*..,._„, l r #_3281C !PARTNERSHIPr M.....� # LLC ril # L :.__.. COMPANY NAME E.F. WINSLOW PLUMBING & HEATING 1 ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH ' STATE [ MA j ZIP L _ 02664m TEL 508-394-7778 I [ 8-396 FAX CELL N/A . EMAIL [ SPECTIONS@EFWINSLOWCOM The Commonwealth of Massachusetts ." • Department of Industrial Accidents 9=.-..7• .-=,;=tir Office of Investigations a.. --..„4,_. tl �`t ., Lafayette City Center `R '' 2 Avenue de Lafayette, Boston, MA 02111-1750 .ia- 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): 1.0 I am a employer with 90 employees (full and/ 5. El Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.El 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.El We are a corporation and its officers have exercised 9. El 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.❑ 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:01/01/2022 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 ' e1 the ins and penalties of perjury that the information provided above is true and correct. Signature: Y . Date: 01/02/2021 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): 1.0Board of Health 2.1=1 Building Department 3.❑City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'rt' `-/ II CITY YARMOUTH MA DATE November 30,202 PERMIT# BLDP-22-003072 JOBSITE ADDRESS 162 PLEASANT ST OWNERS NAME ANSCHUTZ MARKS TRS G OWNER ADDRESS ANSCHUTZ REVOCABLE TRUST 162 PLEASANT ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED:YES❑ NO❑ 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 ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY❑ BOND ❑ 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. PLUMBER-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP©MGF❑JP 0 JGF❑ LPG] ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsna.efwinslow.com S3±ON M31A32i NYld #JIIN213d $ 33d ❑ ❑ 111A1H3d 3H1 SY S3A213S NOIlV011ddV SIHL oN soA S2ION NO1133dSNI 1VNId ICING 3Sf1210103dSNI HOd 39Vd SIH1 S3lON NO1133dSNI SVO HDflOH MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r' a WEs tin CITY 'S YARMOUTH MA DATE 11/23/2021 _ _ PERMIT # Z- 3v�1 �,, — JOBSITE ADDRESS 162 PLEASANT ST, S YAR,OUTH, MA 02664 $OWNER'S NAME MARK GOWNER ADDRESS ;SAME J TEL1(508)398-3488 :FAX TP PE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES 7 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 I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES v NO ; _ . I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ` v ' 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 0 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 I a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ......_,.. 0 1' -' ,...p .,--- PLUMBER-GASFITTER NAME 3 STEPHEN WINSLOW 1 LICENSE # 12298 SIGNATURE MP MGF Ll JP L.I JGF y,., LPGI CORPORATION # 3281 C PARTNERSHIP uFy,w # LLC ; # , .,,. H._. COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH 1 STATE MA 'ZIP i 02664�TEL 508-394-7778 FAX 508-394-8256 CELL. NIA EMAIL,, INSPECTIONS@EFWINSLOW.COM F �. The Commonwealth of Massachusetts • Department of Industrial Accidents 9=7-= .--,( Office of Investigations e-�- 1;) Lafayette City Center ". """A s 2 Avenue de Lafayette, Boston, MA 02111-1750 . ,.7:,_-', . 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.ElWe 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#I. 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 the ins and penalties of perjury that the information provided above is true and correct / 01/02/2021 Signature: 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): 1.11Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia