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HomeMy WebLinkAboutBLDP&G-22-007023 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK lk 7.3--� CITY YARMOUTH MA DATE 6/6/22 PERMIT# BLDP-22-007023 } JOBSITE ADDRESS 37 LONGFELLOW DR OWNER'S NAME MOYNIHAN GIOVANNA A TRS P OWNER ADDRESS PELLEGRINI JOSEPH TRS 82 BOUTELLE ST LEOMINSTER,MA 01483 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW:0 RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES El NO El FIXTURFS 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 0 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 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY SYARMOUTH 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 y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ',xi:: CITY YARMOUTH (PORT) �.._; MA DATE 5/31/22 PERMIT # JOBSITE ADDRESS 37 LONGFELLOW DRIVE I OWNER'S NAME MOYNIHAN P OWNER ADDRESS SAME _ TEL 617-645-4422 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ri EDUCATIONAL Li RESIDENTIAL ED PRINT CLEARLY NEW: RENOVATION REPLACEMENT: PLANS SUBMITTED: YES 0 NO'--/ FIXTURES Z FLOOR-) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ,..... I r CROSS CONNECTION DEVICE ' r i DEDICATED SPECIAL WASTE SYSTEM I I -1 ---1 1- I— r------ir 1 r- am DEDICATED GREASE SYSTEM y DEDICATED GRAY WATER SYSTEM ---r A_ E _ _..� i; DEDICATED WATER RECYCLE SYSTEM f w.._.� _ I' it E...- j�.._.� 1__. ., _ �. 31 B. € l -if DISHWASHER5 .. . 11 all DRINKING FOUNTAIN ! .-® 1 111111 ' FOOD DISPOSER -__--_ �. .. FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) 1 I __ ;' IIMMilallilliFillill __. KITCHEN SINK 1111111Mill ..... . �. . LAVATORY ._ I . .,....., ROOF DRAIN L I__.: J , il SHOWER STALL , ,, - IOW i i SERVICE / MOP SINK _ ;11111'INS 1111111111__„_. II-- - ' i r TOILET I URINAL [� WASHING MACHINE CONNECTION rill _ WATER HEATER ALL TYPESaunlIlIllam6T11116IIIII,IlIllnaiM-Hmj%11: ' . WATER PIPING _IIIIIIIIIIIMM 1111111MIMMEMIIIM 11111111FIMM MR MI 1 NMI MO . MI= MII __ I IIINOM �_ __�.m �._ �. _ - .- .___ . . ` a 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 s 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 A 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 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 com lia i� with II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW 98 JLICENSE # SIGNATURE MP JP CORPORATION-71# 3281C PARTNERSHIPD# v LLCr ]# C._ COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 i TEL 508-394-7778 FAX 508-394-8256 j CELL N/A I EMAIL [iPEOTIONS .EFWINSLOWCOM The Commonwealth of Massachusetts Department of Industrial Accidents xi sra Office of Investigations Lafayette City Center r 2 Avenue de Lafayette, Boston,MA 02111-1750 'b=cam=%� 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): I.© 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.❑ 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#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-'�-�en��the ���d penalties of perjury that the information provided above is true and correct. Signature: 7' 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): 10Board of Health 2.0 Building Department 30 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 [June 06,2022 'PERMIT# BLDP-22-007023 �'� JOBSITE ADDRESS 37 LONGFELLOW DR OWNERS NAME MOYNIHAN GIOVANNA A TRS G OWNER ADDRESS PELLEGRINI JOSEPH TRS 82 BOUTELLE ST LEOMINSTER MA 01483 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED:YES 0 NO 0 FIXTURES FLOORS-s 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY❑ BOND El 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 I LICENSE# 112298 I SIGNATURE MP El MGF❑JP El JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: [STEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH ISTATE MA ZIP 026641207 TEL I FAX CELL EMAIL Iinspections(aefwinslow.com S310N M31AR! NVld #.UV0:13d $ :33J II112U3d 3H1 SV S3A213S NOLLV011ddV SIHI ON Se), S310N NO1103dSNI 1VNid AlNO 3Sf O103dSNI ZIOJ 39Vd SIHI S310N NO1103dSNI St/9 HOflO MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F� �W a s CITY LYARMOUTH (PORT) MA DATE 5/31/22 PERMIT # 2 �a L JOBSITE ADDRESS 37 LONGFELLOW DRIVE ,OWNER'S NAME MOYNIHAN GOWNER ADDRESS SAME TEL 617-645-4422 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: l PLANS SUBMITTED: YES NO APPLIANCES -1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .. ..,.. __ BOOSTER , �;,m 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 .. meµ._ - INSURANCE COVERAGE I have a current liabilityinsurance policyor its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ., NO � q qm Li I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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:*'i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 0 1..f PLUMBER-GASFITTER NAME STEPHEN WINSLOW , LICENSE # 12298 SIGNATURE MP v MGF JP JGF LPGI LI CORPORATION i # 3281 C PARTNERSHIP # LLC # COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE ' MA ZI P 02664 1TEL 508-394-7778 FAX 508-394-8256 CELL' N/A JEMAILINSPECTIONS@EFWINSLOW COM ••• •: '::J:A„�3ti`,bib#;ii4tuYR(4tkSdi»�kpi&bda�E?:: ,. _ .,:';' ....:,.,3:i.......... .:::. :: The Commonwealth of Massachusetts Department of Industrial Accidents --_` Office of Investigations 11 =: - Lafayette City Center `^�M 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.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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4.ElWe 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:01/01/2023 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 and 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): 1.0Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia