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HomeMy WebLinkAboutBLDP&G-23-001206 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 9/6/22 PERMIT# BLDP-23-001206 fl4 JOBSITE ADDRESS 63 CROWES PURCHASE OWNER'S NAME Bruce Loughlin P OWNER ADDRESS MA 01516 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:❑ REPLACEMENT❑ PLANS SUBMITTED: YES NO❑ 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 El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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 LICENSI'1Q298 SIGNATURE MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# 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 , �' _' CITY YARMOUTH (WEST) MA DATE 8131/22 PERMIT # Z3 JCBSITE ADDRESS 63 CROWES PURCHASE OWNER'S NAME BRUCE LOUGHLIN POWNER ADDRESS SAME unv TEL 508-771-1920 , FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL _ 1 RESIDENTIAL EI PRINT CLEARLY NEW: L, ,H RENOVATION: „H REPLACEMENT: LI PLANS SUBMITTED: YES I_, ... NOD FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ; .— ,_s .H1:. ..�::. ,'. CROSS CONNECTION DEVICE DEDICATED SPECIAL_ WASTE SYSTEM j � .. ...._,,,,, �'f $ter --, - , DEDICATED GAS/OIL/SAND SYSTEM m - ..- DEDICATED GREASE SYSTEM r _... _ . DEDICATED GRAY WATER SYSTEM t 1 DEDICATED WATER RECYCLE SYSTEM — I INN 1 ---in- ' .• ' DISHWASHER j DRINKING FOUNTAIN �� [� ��� �_ p FOOD DISPOSER ... < __ # ..... r tI FLOOR /AREA DRAIN ::... I f _�_i .-..___ mm_. `,- _ ME: M INTERCEPTOR (INTERIOR) 3 I :_,. __ = .EIEKITCHENSINK ! i 1- 1- M ` LAVATORYIt , m. -41 • ROOF DRAIN 1 .,,..�i. - -1— SHOWER STALL j i 1 SERVICE / MOP SINK r II. .: 'immit rI, MR 1111. iiM I _.: i .:.. TOILET ------1- -I 1 i=, A URINAL ,.,., _ 17 1.I I , - 1111111 WASHING MACHINE CONNECTIONit;._, _� _ " m.....a. I � ._. i.. : ._: : :. .._,.., _ WATER HEATER ALL TYPES 1 ;� - 11 WATER PIPING 1111111 111111111.1 OTHER H I I - ._:...:: .. ...., .::.'e a.._...._. s .aumc. 1:711--—-"--1. INN r---1._ i --- --ir:-7 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 TYPE OF INDEMNITY i 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. CHECK ONE ONLY: OWNER AGENT El 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 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 co lia with II ertine proYisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW .LICENSE # 112298 SIGNATURE } MP; JP .v___ CORPORATION El# 3281C (PARTNERSHIP; # J LLC # COMPANY NAME 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 IIiSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 9,... ,,. (7; 4t1 Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 '� i Ic�=� 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 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. 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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ 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:01/01/2023 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 }y-Hn the 'iinns and penalties of perjury that the information provided above is true and correct. 12/01/2021 Signature: 7' 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): 1FJBoard of Health 2.0 Building Department 3.1=1 City/Town Clerk 4.11Licensing Board 5.❑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 j MA DATE September 06,202 PERMIT# BLDP-23-001206 JOBSITE ADDRESS 63 CROWES PURCHASE OWNER'S NAME Bruce Loughlin G OWNER ADDRESS MA 01516 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS BSM 1 2 :l 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 ❑ 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 LI MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH SATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectioisanefwinslow.com S31ON M31A3?J NVId #11V d $ 333 ❑ ❑ 11111?J3d 3H1 SV S3Aii3S NOI1VOIlddV SI1-11 oN saA S310N NO1103dSNI 1VN13 hINO 3Sfl 210103dSNI?103 39Vd SIH1 S31ON NO1103dSNI SVO HOfON MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _; ,• CITY YARMOUTH (WEST) 1 MA DATE! 8/31/22 PERMIT # 2 1 1 > JOBSITE ADDRESS 63 CROWES PURCHASE OWNER'S NAME BRUCE LOUGHLIN OWNER ADDRESS SAME1 TEL 508-771-1920 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL -' EDUCATIONAL ( RESIDENTIAL CLEARLY NEW: RENOVATION REPLACEMENT: ' � PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS-0 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 • ,., ,,. , INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY w 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 rj SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted o- 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 a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t/ PLUMBER-GASFITTER NAME STEPHEN WINSLOW j LICENSE # 12298 SIGNATURE MP MGF : JP JGF LPGI CORPORATION # 3281C PARTNERSHIP # §§ � LLC # :.:.,:,:n31. :,:SKi:A&NW#K66M;YAl4d'S&R 'AMUW„abe'AiF,u syFi COMPANY NAME: E.F. WIN-SLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE v. MA ZIP 102664 TEL 508-394-7778 FAX[508-394-8256 CELL` N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents ��rl�l�t'tl Office of Investigations rest._ Lafayette City Center ��, yy 2 Avenue de Lafayette, Boston,MA 02111-1750 ,5,A.. "-' f 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 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]** 11.❑ 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:01/01/2023 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 ins a d penalties of perjury that the information provided above is true and correct. Signature: ?' 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): 1.1=1Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.11Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia