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Home My WebLink AboutBLDP-21-001764 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • o. CITY YARMOUTH MA DATE 10/5/20 PERMIT# BLDP-21-001764 JOBSITE ADDRESS 443 LONG POND DR OWNER'S NAME ROSSI VIRGINIA P OWNER ADDRESS 163 ARNOLD RD FISKDALE,MA 01518 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL D PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ NO El FIXTURES 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 1 WATER HEATER 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 LICENSE 1Q298 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 PERMIT � ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =�� is, CITY 1 j i/ 1 MA DATE 1 J ' PERMIT# 0 u)p-zi--Doilict ...•_...... JCBSITE ADDRESS . `-� (1.3 ._.uv/!N�� n �V . L_ 5out-k_____, OWNER'S NAME _ _diP_/L ___ ti 0 ‘ , .11r10Jt V OWNER ADDR ESS , W_ _ 01 __. __�. .._.._. _ - TEL SIB if 4 pi Y IFAX ________J TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 71 RESIDENTIAL Et---- PRINT CLEARLY NEW: _..- RENOVATION: [J REPLACEMENT: L.-"' PLANS SUBMITTED: YES NOR FIXTURES -1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 111111311111111 _ I.____11,___.__- IL.:._ 'I_- 1--- _ _ - - _ Milt MIN --- -- CROSS CONNECTION DEVICE 1111MII ___--_ L_ ir 1--_ I ) - --- I DEDICATED SPECIAL WASTE SYSTEM I_ ___-i[ IL__,IL I IL _ L= - 7 DEDICATED GAS/OIL/SAND SYSTEM -- -- DEDICATED GREASE SYSTEM ---,--- ,__.. _ —_ _ UIMI -:_ ___.;:.`_1L --- MM',_11111111 DEDICATED GRAY WATER SYSTEM L�- L — � . _ .. __ _. iiiiiiI ._. . _ _. Il_ _ ,' . ii _ . - DEDICATED WATER RECYCLE SYSTEM _ L _1 I 1 C imumcm DISHWASHER MINNWMIIIIIMMUMFONIIIMMONIMINIMI --: - I---- IMIN DRINKING FOUNTAIN -III FOOD DISPOSER ��— _ -- 1 ( 1, ,1 ._4 _ 1 ._ FLOOR J AREA DRAIN 1 �, r� "t ' —= T __._..�___ INTERCEPTOR (INTERIOR) MI - 1 ___ _ - _- :: . KITCHEN SINK I -- _1 _: - -_l.:- __ . I LAVATORY -• - -- -_ .. ,, 11111111.11111111111111 _ 11 ROOF DRAIN _ ..._ _ . M SHOWER STALL ihidau _ _777.moin SERVICE I MOP SINK _• _ Saingill.611111 j 11111111.11, TOILET URINAL aalnillt1111111OMITI- ' snlill': _ _ _ _, WASHING MACHINE CONNECTION [� _ �.. WATER HEATER ALL TYPES _ - �L �_._.__.:_ .1111111imi Wm WATER PIPING _�. _: _y _ -__. + 1 _ _ umr- OTHER --_ ._.__�.._.._.__ _� --f— nowlimumuunip__.._ ...-_1n..:.1....f�.tt l-. c�w _y. � �.yC�(..tik'.L'11=i�`�.�"�.53._ - _ IF,_,__„__�s'�'<..ela'��41Y-'^�-w�ldd�niRV:~rci�b$ ._ moil-Mimi nit iiiiiimignitaMINIFINIFORF--_- i J INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES I.] NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY „ , OTHER TYPE OF INDEMNITY [._ l BOND {A 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 hereby certify that all of the details and information I have submitted or entered regarding this application are true r to 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 co Ii wit II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 111 ,� .--.,,, - /� -S- r— NAME STEPHEN WINSLOW LICENSE # ( 12298 I SIGNATURE — v MP DI JP® CORPORATION 0# 3281C PARTNERSHIP®# 1 LLC 0#.Tv_. .. _..__r__.,, L � COMPANY NAME E.F.WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE _ I CITY SOUTH YARMOUTH STATE MA ZIP 02664 • EL 508-394-7778 I FAX 1508-394-8256 I CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM I H' r 4 • ,, The Commonwealth of Massachusetts Department oflndustrialAccidents ,19 Office of Investigations • Lafayette City Center 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): 1.0 I am a employer with 90 employees(full and/ 5. ❑Retail 2.❑ or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 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 re uired q ] 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 no employees. [No workers' comp.insurance required]** 10.0Manufacturing 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no.employees. [No workers' comp insurance req.] 12.9 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.#1909AExpiration te:01/01/2021 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 perjury that the information provided above is true and correct. Signature: Date: 01/02/2020 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.p Building Department 3.0 City/Town Clerk 4.[]Licensing Board 50 Selectmen's Office 6.[Other Contact Person: Phone#: