Loading...
HomeMy WebLinkAboutBLDP&G-22-007179 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK y, CITY YARMOUTH MA DATE 6/13/22 PERMIT# BLDP-22-007179 _'_ JOBSITE ADDRESS 16 EAGLE LOOP OWNER'S NAME BUTLER THOMAS F JR P OWNER ADDRESS 16 EAGLE LOOP YARMOUTH PORT,MA 02675-1106 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑ 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/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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ 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 W298 SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# J COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 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 d ��73:1 CITY YARMOUTH MA DATE 6/2/22 1 PERMIT # 77 I 7 ci JOBSITE ADDRESS 16 EAGLE LOOP YARMOUTHPORT MA 02671 OWNER'S NAMEITHOMAS BUTLER 1 _.._ POWNER ADDRESS SAME i TEL 5083626840 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL RESIDENTIAL ' PRINT CLEARLY NEW: RENOVATION:[T REPLACEMENT: v PLANS SUBMITTED: YES El NoI FIXTURES 1 FLOOR--► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _; i li 11_ ., „..41.....,_ ' - CROSS CONNECTION DEVICE . DEDICATED SPECIAL WASTE SYSTEM L .. . 11 _. _ i if , ... Mt t ___ _ , U DEDICATED GAS/OIL/SAND SYSTEM r MO 1111111 MI NM NM ii DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEMI DEDICATED WATER RECYCLE SYSTEM ----i—E--. II DISHWASHER 1.. _i 11 II t ,. _ IF ,.._.- k _ DRINKING FOUNTAIN L _ . - � _ �� 0 ' A, ._., : [ , — —FOOD DISPOSER r - 1� ' �-- FLOOR l AREA DRAIN INTERCEPTOR (INTERIOR) i �. -'r_ 6 KITCHEN SINK I �. .III.., -�... _ - �__ LAVATORY L______ _�._��_. _ r _ _. --1 ROOF DRAIN _ _ � � _ — I y ` - � --- fir - -_—__ SHOWER STALL I , L 11-- iiT.. .. _ . I. _ ._. -1_ SERVICE / MOP SINK TOILET ,111111 1 ,.. ' irt E ._ L.. URINAL MIN NM -__ii i 7 ,E_ 1~ J WASHING MACHINE CONNECTION NIB L ME Eli WATER HEATER ALL TYPES [ 1t[+ , - r 111.111 WATER PIPING NEI INN iL , -1(- 7 'L I OTHER 1.1. MEI' MIR NM ._ I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES iTi NO 0 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. CHECK ONE ONLY: OWNER AGENT `o 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 co lia with li ertine pro"'isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (---- PLUMBER'S NAME I STEPHEN WINSLOW LICENSE # L12298 J SIGNATURE +� ' MP JP CORPORATION # 3281C IPARTNERSHIPE3# LLC # I VI COMPANY NAME E.F. WINSLOW PLUMBING & HEATING 1 ADDRESS 8 REARDON CIRCLE 1 CITY( SOUTH YARMOUTH STATE ' MA ZIP [02664 TEL 1508-394-7778 FAX 508-394-8256 CELL [-NIA EMAIL INSPECTIONS@EFWINSLOW.COM r-' s The Commonwealth of Massachusetts Department of Industrial Accidents z Office of Investigations Lafayette City Center �•-% 2 Avenue de Lafayette, Boston,MA 02111-1750 —s,•,. 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 El 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 cerpf Ie the ins and penalties of perjury that the information provided above is true and correct. �� ,� 01/02/2021 Signature. 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 30 City/Town Clerk 4.0Licensing 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 9k3F) CITY YARMOUTH MA DATE [une 13,2022 'PERMIT# BLDP-22-007179 JOBSITE ADDRESS 116 EAGLE LOOP I OWNER'S NAME BUTLER THOMAS F JR G OWNER ADDRESS 11-6-EAGLE LOOP YARMOUTH PORT MA 02675-1106 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT© 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 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 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❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY 5 YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(Aefwinslow.com S310N M3IA32i NYld #IIIN213d $:333 ❑ El 111A183d 3H1 SV S3Ab3S NOIlVOIlddd SIHl oN seA S310N NO1103dSNI 1VNId AlNO 3Sl 2J0103dSNI 210d 3OVd SIR! S310N NOI103dSNI SVO HOflO MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH I MA DATE 612122 I PERMIT # k\--7.,„- -,, ,_-.-5,1 JOBSITE ADDRESS 16 EAGLE LOOP YARMOUTHPORT MA 0267I OWNER'S NAME ITHOMAS BUTLER GOWNER ADDRESS SAME I TEL 5083626840 FAX PRINOTR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL 4 CLEARLY NEW: RENOVATION: REPLACEMENT: [ PLANS SUBMITTED: YES® NOP APPLIANCES Z FLOORS-0 BSM 1 2 3 4 5 ] 6 7 8 9 10 11 12 13 14 BOILER ..r...._ . ._,. BOOSTER ii. �, CONVERSION BURNER , COOK STOVE DIRECT VENT HEATER ' r.�, r DRYER [ FIREPLACE [ i.� - __.., .�... , FRYOLATOR r FURNACE rii., — 17 GENERATOR L _ T �� M. GRILLE INFRARED HEATER _ LABORATORY COCKS � 4— MAKEUPAIRUNIT �' OVEN 1-- - - igi - _ POOL HEATER !. ROOM / SPACE HEATER ROOF TOP UNIT r ,..-. I"._ TEST UNIT HEATER _ ..Alii.. .161=W rbalingilitirOlow_ UNVENTED ROOM HEATER _T__ _ WATER HEATER I _. OTHER 7- - lt ,�. _ . INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ' NO El 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 E" AGENT ...IN. SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate 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 compliant i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Cm\-- ? ' / L. s PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE #112298 SIGNATURE ,• ' MP 0 MGF JP JGF LPG! CORPORATION v # 3281C —I PARTNERSHIP j#{ 1LLCLJ# .11.11 • — COMPANY NAME:1 E.F. WINSLOW PLUMBING & HEATING ADDRESS 18 REARDON CIRCLE I CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 I FAX 508-394-8256 CELL' N/A !EMAIL I SN PECTIONS@EFWINSLOW.COM j ; \ The Commonwealth of Massachusetts Department of Industrial Accidents ;9 �` ) + Office of Investigations OVa Lafayette City Center 'i—II 2 Avenue de Lafayette, Boston,MA 02111-1750 N-<,.... 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_ 11 Restaurant/Bar/F.ating 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.❑ 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. #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 ce ' i the ins and penalties of perjury that the information provided above is true and correct / 01/02/2021 Signature: ? .•... 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): I f 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