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Home My WebLink AboutBLDP-23-001451 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w.: 3 CITY YARMOUTH MA DATE 9/19/22 PERMIT# BLDP-23-001451 JOBSITE ADDRESS 14 GEORGETOWN LANDING OWNER'S NAME DEWITT CHARLOTTE J P OWNER ADDRESS 14 GEORGETOWN LANDING SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL PRINT CLEARLY NEW:❑ 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 1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER 1 1 OTHER DESCRIPTION:waste/vent piping icemaker 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❑ 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'S NAME Stephen Winslow LICENSE N2298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL r 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 _.r_ ,., a_n.,..... MA DATE 9/14122 1 PERMIT # JOBSITE ADDRESS 14 GEORGE TOWN LANDING OWNER'S NAME CHARLES DEWITT POWNER ADDRESS 249 WEST NEWTON ST UNIT 8 BOSTON MA s TEL 508-398-6339 FAX , TYPE OR OCCUPANCY TYPE COMMERCIAL ,.,• EDUCATIONAL CD RESIDENTIAL [.i I PRINT CLEARLY NEW: Ej RENOVATION: I i REPLACEMENT: 1 v _ PLANS SUBMITTED: YES I ._ NO FIXTURES -1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 I ______ MIR CROSS CONNECTION DEVICE I iInil AM I _ DEDICATED SPECIAL WASTE SYSTEM € In r �_ lr le DEDICATED GAS/OIL/SAND SYSTEM _i _ -1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM an 11111111MIIIII 11111 1111111111111IO NI 1111111111 DEDICATED WATER RECYCLE SYSTEM lnllillrMIIIIIII MIR 111111101111111 Illiali. MI=I 11111111111110.111 aSHW SHE r DRINKING FOUNTAIN j111111111111111111111i111111111111111 11111111111 MIN 1111111111.$11111111111111111111111 FOOD DISPOSER 11111111111.111111101111111111M_ -. M MI FLOOR /AREA DRAIN i_. INTERCEPTOR (INTERIOR) Pw ._:IIIII_._ 1111111 rig Mil 11111111 1111.IIIIII KITCHEN SINK 1 _- I LAVATORY _ c I I - ROOF DRAIN li. .. : 1 SHOWER STALL - SERVICE / MOP SINK TOILET NM NM MM.MM. SI . .. MI IIIII URINAL MI MIIIIIIIIIIIM 111111111111111h 11_ . i ..._.__ WASHING MACHINE CONNECTION -,I! MI I, WATER HEATER ALL TYPES € — _ { WATER PIPING ._. ..... ...... ..- I OTHER ICE MAKER 1. r..__..W__ E ,____ r_____11 ' WASTENENT PIPING 11111111611111111.11111i: l I3 ,I _..._ 1.- I i t I l -d j - .p .� .... ..-..� ,�. ,� :... minst........ . — _ - .r ......ram._ F -i, , i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES - NO ..._r_. 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 [_ i AGENT z.._ 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 Ii with II ertine pro'isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME i STEPHEN WINSLOW i LICENSE # 12298 SIGNATURE .. �- - MP JP CORPORATION i # 3281C PARTNERSHIPS#I I LLC , # COMPANY NAME E.F. WINSLOW PLUMBING & HEATING 1 ADDRESS i 8 REARDON CIRCLE J .._......j___ CITY SOUTH YARMOUTH STATE [-----M----A--1 ZIP 02664 TEL 508 394 7778 FAX 508-394-8256 JCELL N/A EMAIL [11\1SPECTIONS@EFWINSLOW.COM —. The Commonwealth of Massachusetts -,o Department of Industrial Accidents - —_ Office of Investigations Lafayette City Center �' 2Avenue de Lafayette, Boston,MA 02111-1750 ° 1y%f (. ._ ..�I wwwmass.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. ❑ Restauratit/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 cap^city. [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]** 11.1711 Health 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#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��the ins and d penalties of perjury that the information provided above is true and correct. �^\ G� 12/01/2021 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): I.DBoard 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