Loading...
HomeMy WebLinkAboutBLDP&G-23-001363 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ag CITY YARMOUTH MA DATE 9/14/22 PERMIT# BLDP-23-001363 f I{�.. JOBSITE ADDRESS 1300 ROUTE 28 OWNER'S NAME TRAN FAMILY LLC P OWNER ADDRESS 156 SEA ST QUINCY,MA 02169 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑v PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES El 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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 at of the details and information I have submitted or entered regarding this application are We 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 1P298 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 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 S PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK —T '_r CITY }YARMOUTH SOUTH MA DATE t8/25122 PERMIT # Z3 ' 3 / JOBSITE ADDRESS 11300 MAIN ST (RTE 28), S YARMOUTH, MA I OWNER'S NAMETROY TRAN 10•111111MININIM .- _ POWNER ADDRESS SAME 1 TELf508 398-5592 b FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL E vj PRINT CLEARLY NEW: Ei RENOVATION: ' REPLACEMENT: T PLANS SUBMITTED: YES LI NO FIXTURES Z FLOOR--► BSM 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE L MI I , DEDICATED SPECIAL WASTE SYSTEM iiiimmirmunam---msaiwwwww mot IMIIIMMIlli_ DEDICATED GAS/OIL/SAND SYSTEM � E DEDICATED GREASE SYSTEM .... '' I, ;� DEDICATED GRAY WATER SYSTEM I jI I �'_ _ . .._ II III F .: DEDICATED WATER RECYCLE SYSTE�,q ! �'� r ���, L ,;--- —11 �� DISHWASHER I MINIM °. i i � L I DRINKING FOUNTAIN . I FOOD DISPOSER 1111111111111.111111111111111MinsraillIM in MIIIIIIWBIIIIIMIFM FLOOR / AREA DRAIN _ 1 INTERCEPTOR (INTERIOR) T h1 KITCHEN SINK LAVATORY — — �'I IIII _ Im��_ ._ I ROOF DRAIN SHOWER STALL a1 L . SERVICE / MOP SINK MIIIIIIIIIIIIMININ11111111111111.10.11.01MMITIMIEM_ TOILET ,_.. (. MMM URINAL IMIIIIIIMIIIIIIIIIIIMIIIIIIIIIIIIIINIIIIIIIIMIIIIIIINIIIIIIIIIIIIIMIIIIIMEMIFIIII WASHING MACHINE CONNECTION I I I OM_I_111 I I INNI WATER HEATER ALL TYPES �� »I it I WATER PIPING 1.1111111111111011111111111.111111MinalmilsimilliiiIIIIIIIIIII OTHER ' I f IMl ! _ _ , t , r , _ i, ii----i , _ 4.---- -11111M b____-d -1/- _1 a .. I I III INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO ri IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I J OTHER TYPE OF INDEMNITY El 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 Li AGENT I, ._ SIGNATURE OF OWNER OR AGENT hereby certify that a I 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 perm t issued for this application will be in corn Ii. : with II ertine pro' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW LICENSE # 12298 71 SIGNATURE MP' � i JP Ell CORPORATION I# 3281C IPARTNERSHIP r 7# I LLCM # COMPANY NAME E.F. WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE ! MA I ZIP ' 02664 TEL # 508 394-7778 FAX 508-394-8256 CELL N/A EMAIL ENSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents � � �1 `. Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 ' ,'M 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. J 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.❑ 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 cer the in and penalties of perjury that the information provided above is true and correct. Signature: 1' " ! 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.❑City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.0 Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '11s < CITY YARMOUTH MA DATE September 14,202 PERMIT# BLDP-23-001363 JOBSITE ADDRESS 1300 ROUTE 28 OWNER'S NAME TRAN FAMILY LLC G OWNER ADDRESS 156 SEA ST QUINCY MA 02169 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED:YES 0 NO 0 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 I 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY❑ BOND 0 OWNERS 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 permil 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 El MGF El JP El JGF El LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# ILLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(aefwinslow.com c S310N M3IA321 NVId #IIW2i3d $ :33d ❑ ❑ 111V:13d 3H1 SV S3A83S NOILVOIIddV SIH1 oN seA 8310N NO11O3dSNI 1VNId 1lN0 3Sfl 21O103dSNI 2JOd 3OVd SIHI S310N NOI103dSNI SVO HJl0N MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK v=u CITY YARMOUTH (SOUTH ..,_ MA DATE 8/25/22 I PERMIT # aar JOBSITE ADDRESS 1300 MAIN ST (RTE 28), S YARMOUTH, MA 1 OWNER'S NAME TROY TRAN GOWNER ADDRESS SAME TEL 508 398-5592 JFAX TPRIN OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL , RESIDENTIAL gyp' CLEARLY NEW: RENOVATION: REPLACEMENT: � PLANS SUBMITTED: YES . b NO v APPLIANCES -1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER ,;,. COOK STOVE I DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR r— FURNACE GENERATOR 1 . 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 .-_---w- -- ;:_: : _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES j v NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY , OTHER TYPE INDEMNITY BOND L 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 r AGENT f 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 Statc Plumbing Code and Chapter 142 of the General Laws. C--) ' / 7' .l'' PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE #` 12298 SIGNATURE MP v MGF JP JGF LPGI CORPORATION - # 3281C PARTNERSHIP , # i LLC EJ# COMPANY NAME: =.F. WINSLOW PLUMBING & HEATING ADDRESS 18 REARDON CIRCLE CITY SOUTH YARMOUTH g STATE I MA ZIP I02664 TEL 508-394.7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM !t^ \ The Commonwealth of Massachusetts Department of Industrial Accidents f=-P Office of Investigations r qk Lafayette City Center '\L 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/Bating 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]** 11.0 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. 12/01/2021 Signature: Y hA -.... 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): 1.1=1Board of Health 2.1=1 Building Department 3.1=I City/Town Clerk 4.❑Licensing Board 5.❑Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia