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HomeMy WebLinkAboutBLDP&G-23-000935 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �)C- �'�` CITY YARMOUTH MA DATE 8/22/22 PERMIT# BLDP-23-000935 JOBSITE ADDRESS 287&289 OLD TOWNHOUSE RD OWNER'S NAME ECCLES GLENN T P OWNER ADDRESS ECCLES DEBORAH LEE 50 ACORN LN DENNIS,MA 02638 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(INTE:RIOR) _ 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 D 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 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#R298 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 • FAX CELL EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES \es No THIS APPLICATION SERVE AS THE ❑ FEES S PERMITS PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ ", __ CITY 1YARMOUTH (SOUTHI 1 MA DATE 8/18/22 JPERMIT # 23- ° cri 31 JOBSITE ADDRESS i287 OLD TOWN HOUSE, S YARMOUTH, MA I OWNER'S NAMEFGLENN ECCLES OWNER ADDRESS ,0 ACORN RD, DENNIS, MA 02638 ,,,,,_,_rniTEL 508 414-0879 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL :, ! EDUCATIONAL RESIDENTIAL Fl PRINT CLEARLY NEW: L i RENOVATION: : y REPLACEMENT: PLANS SUBMITTED: YES 0 NOE] FIXTURES 7 FLOOR—I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB - - "-----_ ,r ....� , ---,--,..,!!----1_, —1,.... CROSS CONNECTION DEVICE f"------ ! _._ DEDICATED SPECIAL WASTE SYSTEM r_..__._ „d IINN MI MI 1111 --1 . .. DEDICATED GAS/OILISAND SYSTEM a,.:."M.. E: `.�.�„ 1,,,, T 'r _ o_ .w.. DEDICATED GREASE SYSTEM L- ._ _ 1 . .� ____. ; � � DEDICATED GRAY WATER SYSTEM r_.,w. ' --,, . DEDICATED WATER RECYCLE SYSTEM, 1 L17. j�" � _ 11-11-'1_ 11-11-'1I � � , 1,,-- .1 i DISHWASHER rA DRINKING FOUNTAIN FOOD DISPOSER �i = 1 .� . FLOOR /AREA DRAIN 4 INTERCEPTOR (INTERIOR) KITCHEN SINK ."." LAVATORY H 13 _11 - ,,, t_ ROOF DRAIN r ... .� _ SHOWER STALL I SERVICE / MOP SINK _- (_ w I IL -,_ TOILET �..�m_._�1 _ _ � ,_ URINAL ,...._ __ 9if :r WASHING MACHINE CONNECTION _ _ WATER HEATER ALL TYPES 1 . A __ I WATER PIPINGF _.: .... � MINI11111 1 OTHER _ � C I _ _ liiii 111111111111111111111111111111111110111111 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Fl NO Ej IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v OTHER TYPE 0:= INDEMNITY 0 BOND E 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 o`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 wcrk and installations performed under the permit issued for this application will be in corn Ii. : with II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 12298 SIGNATURE PLUMBER'S NAMEEiTEPHEN WINSLOW ; LICENSE # MP v6 JP El CORPORATION , v #€3281C IPARTNERSHIPLI#1 [LLC # COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ' ADDRESS FREARDON CIRCLE ) CITY SOUTH YARMO UTH I STATE MA I ZIP 02664 I TEL 508-394-7778 FAX 508-394-8256 CELL N/A i EMAIL FINSPECONS@EFWINSLOW COM y The Commonwealth of Massachusetts Department of Industrial Accidents 9 Office of Investigations Lafayette City Center r'`�, 2 Avenue de Lafayette, Boston, MA 02111-1750 T'4,M(_, _ V `*''!t 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 10.0 Manufacturing no employees. [No workers' comp. 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:01/01/2023 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 and penalties of perjury that the information provided above is true and correct. Signature: Y "` -..- /^---- 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.DBoard of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 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 _1 MA DATE August 22,2022 PERMIT# BLDP-23-000935 JOBSITE ADDRESS 287&289 OLD TOWNHOUSE RD OWNER'S NAME ECCLES GLENN T G OWNER ADDRESS ECCLES DEBORAH LEE 50 ACORN LN DENNIS MA 02638 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ 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 I 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 pe-mit 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 0 MGF ❑ JP[] JGF❑ LPGI ❑ CORPORATION❑# _ PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. ,8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX —1 CELL EMAIL inspect ons a(�efwinslow.com S310N M31A321 NVId #1I141213d $:33d ❑ ❑ 1111d3d 3H1 SV SaAiJ3S N011VoIlddV SIH1 oN saA S3lON NOI103dSNI 1VNId AINO 3Sl 210103dSNI 210d 3OVd SIH1 S310N NO1103dSNI SVJ H0l021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ^ M ,.. .:. CITY YARMOUTH SOUTH MA DATE 08/18122 I PERMIT # Z 3 - oc 3 S" JOBSITE ADDRESS 287 OLD TOWN HOUSE, S YARMOUTH, MA. OWNER'S NAME GLENN ECCLES1 GOWNER ADDRESS 50 ACORN RD, DENNIS, MA 02638 ] TEL (508)737-9482 i FAX _. , TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Li RESIDENTIAL PRINT , CLEARLY , NEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES NO rTil APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 8 9 J 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER } FIREPLACE FRYOLATOR { i FURNACE GENERATOR GRILLE _ i ... INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT 1 TEST _ .......... I UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER _. � _ I __ J INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES v NO Li 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 i AGENT L 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 compliant I a P rtine provision of the Massachusetts State F lumbing Code and Chapter 142 of the General Laws. 0 r ......, . ,....1:....— PLUMBER-GASFITTE:R NAME STEPHEN WINSLOW LICENSE #` 12298 SIGNATURE MP 1 v MGF Li JP i JGF LPG' CORPORATION # 3281C PARTNERSHIP' # LLC #i COMPANY NAME:'E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH 1 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 99 . __i Office of Investigations ': A Lafayette City Center f r 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.❑■ 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]** 4.El We are a non-profit organization, staffed by volunteers, 11.0Health 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: 01/01/2023 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 ce the ins and penalties of perjury that the information provided above is true and correct. Signature: 7' "` l 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): 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia