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HomeMy WebLinkAboutBLDP&G-22-001884 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 10/4/21 PERMIT# BLDP-22-001884 JOBSITE ADDRESS 66 ARROWHEAD DR OWNER'S NAME RENAUD NEAL P OWNER ADDRESS RENAUD BRIDGETTE 66 ARROWHEAD DR YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES NO❑ FIXTURES-I FLOORS—, RSM 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 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 El El FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 14k„ y� CITY YARMOUTH PORT MA DATE i9/29121 JPERMIT # _._ .._.._ ... JOBSITE ADDRESS 1166 ARROWHEAD DRIVE l OWNER'S NAME,BRIDGETTE RENAUD P r- OWNER ADDRESS [SAME TEL 508-360-7882 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL r EDUCATIONAL '__ 3 RESIDENTIAL . PRINT CLEARLY NEW: Li RENOVATION: 0 REPLACEMENT: !_, PLANS SUBMITTED: YES L NO vd FIXTURES Z FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB mil i _ , i J 1_1i a _. . _ CROSS CONNECTION DEVICE , r- L If i 1 I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEMNMI MI _ DEDICATED GREASE SYSTEM � a. � DEDICATED GRAY WATER SYSTEM � _ � � MN DEDICATED WATER RECYCLE SYSTEM ..�R _ yj ... I ........ [�-..�..._. _.._..1 1 [.�._ DISHWASHER '.� , n [.—__ 1-- r....___i —err - i, m -I I----®-i ' 1 1 DRINKING FOUNTAIN FOOD DISPOSER ill=11111111.1.111111111111111111111 MR 111110111110111111111111111111111111111. FLOOR 1 AREA DRAIN 3 1111111.111111111.1111111111111111 MIN 1111111111.11111.11 ... INTERCEPTOR (INTERIOR) 5 j ..: 1 KITCHEN SINK .. _ ._. LAVATORY ROOF DRAIN SHOWER STALL { I I `J MIN_ 1111111111111I . SERVICE 1 MOP SINK TOILET 3 � --. —11--- T __ _, m URINAL r IL L j WASHING MACHINE CONNECTION r Er , �Y WATER HEATER ALL TYPES L,,. y! .. , WATER PIPING ; _ 1, j _ �.. r ., _._ _...._..._ .._. _ s OTHER ,r I,_ I ' 1 I r INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES I l 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 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 i 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 corn lia with II ertine proYisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - . ,.s.� "......-- PLUMBER'S NAME STEPHEN WINSLOW !LICENSE # 12298 SIGNATURE MP JP CORPORATION j # 3281C {PARTNERSHIP# LLC # COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS E 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE [—MA j ZIP 02664 TEL 508-394-7778 __ _ FAX 508-394-8256 CELL N/A _ 1 EMAIL LiNsPEcTioNs© wlNsLowcoM The Commonwealth of Massachusetts Department of Industrial Accidents =-.� f Office of Investigations _ /� Lafayette City Center — �,' 2 Avenue de Lafayette, Boston, MA 02111-1750 \MI 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.LI 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 oc''^ers have exercised 9. ❑ Entertainment their right of exemption per c , §1(4), and we have 10.❑ Manufacturing no employees. [No workers . insurance required]** 11.0 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#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 ' i the ins and penalties of perjury that the information provided above is true and correct. Signature: �' ^w'v''-' 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.❑Board of Health 2.0 Building Department 30 City/Town Clerk 4.1: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 zrey CITY YARMOUTH MA DATE October 04,2021 PERMIT# BLDP-22-001884 JOBSITE ADDRESS 66 ARROWHEAD DR OWNER'S NAME RENAUD NEAL G OWNER ADDRESS RENAUD BRIDGETTE 66 ARROWHEAD DR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL ID 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/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 0 OTHER 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-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsefwinslow.com S310N M31A32i NVId #ilINN3d $:33d El 1IWN3d 3141 SV S3Ai13S NOI1VOIlddV SIH1 oN saA SR ON NO11O3dSNI WNId AINO 3sn H0103dSNI 2JOd 3SVd SIHI S310N NO1103dSNI SMO 11011021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK f rim : . +�_�-y CITY YARMOUTH PORT MA DATE 9/29/21 PERMIT # 2. Z - 1 `1 JOBSITE ADDRESS 66 ARROWHEAD DRIVE I OWNER'S NAME BRIDGETTE RENAUD I G ,__.... .._ , OWNER ADDRESS SAME JTEL5O8-360-7882 FAX L TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 71 RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO v i APPLIANCES 1. 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 I FURNACE GENERATOR GRILLE _ - , INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT 1 OVEN I POOL HEATER ROOM 1 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 LLe NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY , OTHER TYPE INDEMNITY 0 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. CHECK ONE ONLY: OWNER Fj 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 11 ---- ...pes.424-0." PLUMBER-GASFITTER NAME . STEPHEN WINSLOW ( LICENSE # 12298 SIGNATURE MP " MGF JP JGF 7 LPG! cJ CORPORATION v # ' 3281 C 1 PARTNERSHIP # ' LLC # __ COMPANY NAME E F WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 IITEL 508-394-7778 ......:.:. FAX 508 394 8256 CELL N/A JEMAIL, INSPECTIONS@EFWINSLOW.COM ��� The Commonwealth of Massachusetts S Department of Industrial Accidents „—_t!,F Office of Investigations E Lafayette City Center — r' 2 Avenue de Lafayette, Boston, MA 02111-1750 �,',M r)-', 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.ElWe are a non-profit organization, staffed by volunteers, 11.11] 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 cer ' e the ins and penalties of perjuty that the information provided above is true and correct. 01/02/2021 Signature: 7' ' h .4'A _.- 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): 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia