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HomeMy WebLinkAboutBLDP&G-22-003229 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 12/7/21 PERMIT# BLDP-22-003229 o JOBSITE ADDRESS 5 ALEXANDER DR OWNERS NAME MILLS KENNETH R P OWNER ADDRESS MILLS MARTHA M 5 ALEXANDER DR YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTIIRFS 1 FLOORS—, RAM 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: f 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 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 at plumbing work and installations performed under the permit issued for this application wit be In compliance with at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, PLUMBER'S NAME Stephen Winslow LICENSE 112298 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 0 ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK :)lailik.,,,, - ®v, m, CITY E YARMOUTH 1 MA DATE 12J0112021� PERMIT # 22 JOBSITE ADDRESS 15 ALEXANDER DR, YARMOUTH PORT, MA 1 OWNER'S NAME[KENNETH MILLS POWNER ADDRESS !SAME ITEL 508 362-5596 JFAX L TYPE OR OCCUPANCY TYPE COMMERCIAL ED EDUCATIONALi RESIDENTIAL Ej PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 4..._e._ NOS: FIXTURES 1 FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ______ 1 _ mis um iim on CROSS CONNECTION DEVICE Nsy. i _ 1 it { DEDICATED SPECIAL WASTE SYSTEM ; I DEDICATED GAS/OIL/SAND SYSTEM *jII DEDICATED GREASE SYSTEM ! DEDICATED GRAY WATER SYSTEM , t _____, , _, 1, DEDICATED WATER RECYCLE SYSTEM I ' i . . .... .. " UI DISHWASHER Willillinliiiii MI 111.11: u ;, DRINKING FOUNTAIN III _ FOOD DISPOSER 11- ._.._. FLOOR I AREA DRAIN IIIII I± INTERCEPTOR (INTERIOR) KITCHEN SINK 11111. " _ , . ..1 , f LAVATORY NM ililli N E ROOF DRAIN t SHOWER STALL NEI _ i,.SERVICE / MOP SINK 1 ...__�.: _. TOILET : URINAL nil Mil NMI ' WASHING MACHINE CONNECTION ;_ WATER HEATER ALL TYPES WATER PIPING gF-- OTHER MM. ,; e... . I IIIIII 11111 3 __ MI[INI IIIIIII v i 'i 1 � I F 1 I _ C — 111111111.111 I ig I , :P i� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES I: , I NO ._ _s IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' , i OTHER TYPE OF INDEMNITY I BOND in 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 v__- 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 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 —7]LICENSE # 12298 SIGNATURE MP J JP -1 CORPORATION #i 3281C PARTNERSHIP[# LLC E..... # COMPANY NAME E.F. WINSLOW PLUMBING & HEATING I ADDRESS [ 8 REARDON CIRCLE CITY ' SOUTH YARMOUTH STATE MA ] ZlP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents _f 9 Office of Investigations Lafayette City Center /t 2 Avenue de Lafayette, Boston, MA 02111-1750 (_ __ Y 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.❑ 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: 01/01/2022 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 penalties of perjury that the information provided above is true and correct. ``//�1 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.❑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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k.s1_ CITY YARMOUTH MA DATE 'December 07,2021 PERMIT# BLDP-22-003229 JOBSITE ADDRESS 5 ALEXANDER DR OWNER'S NAME MILLS KENNETH R G OWNER ADDRESS MILLS MARTHA M 5 ALEXANDER DR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES❑ NO❑ FIXTURES FLOORS-n 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER 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 at 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 El MGF❑JP 0 JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(a)efwinslow.com S31ON MIA NVld #lJW2J3d $ :333 ❑ ❑ 111NJ3d 3H1 SV S3AH3S NOI1Y3llddd SIHI oN saA S31ON NO1103dSNI 1VNIJ /ONO 3Sfl 80103dSNI IOd]0Vd SIHt S310N NOI103dSNI Sd0 HJl1OH MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • � CITY YARMOUTH MA DATE 12/0112021 PERMIT # 2 L S JOBSITE ADDRESS 5 ALEXANDER DR, YARMOUTH PORT, MA 1 OWNERS NAME KENNETH MILLS 1 GOWNER ADDRESS SAME ITEL(508)362-5596 FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL[, PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES i NOE APPLIANCES Z FLOORS—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ____1_ --__' 0 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE _ FRYOLATOR I; 1 FURNACE m l GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 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 ' '' 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 L 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. PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP v MGF L, _ JP `s 1 JGF 0 LPGI L CORPORATION 0# 3281C PARTNERSHIP # LLC 0# COMPANY NAME:1 E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts - . Department of Industrial Accidents __ '' Office of Investigations :p_ Lafayette City Center t,=E--! 2 Avenue de Lafayette,Boston,MA 02111-1750 Akttizo,., 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. ❑RestaurantBar/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]** I1.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, 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 herebyteniej the 9ains 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): lOBoard 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