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HomeMy WebLinkAboutBLDP-22-004487 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK u-*, CITY YARMOUTH MA DATE 2/14/22 PERMIT# BLDP-22-004487 ll, JOBSITE ADDRESS 1 AVERY LN OWNER'S NAME PAQUIN JUDITH L P OWNER ADDRESS FA LN SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO El 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 0 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 I LICENSE 112298 SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ISTEPHEN A WINSLOW I ADDRESS 18 REARDON CIR CITY IS YARMOUTH I STATE IMA I ZIP 1026641207 I TEL I FAX I I CELL I I EMAIL (inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El El FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -- -..-,,... , _,.......1 i "affirfra--= , wantfft 2 iS CITY YARMOUTH (SOUTH) MA DATE 2/4/22 1 PERMIT # Z Li Li 1 JOBSITE ADDRESS 1 AVERY LANE OWNER'S NAME JUDITH PAQUIN P , OWNER ADDRESS I SAME TEL 508-398-8192 FAX'- TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL Li RESIDENTIAL ri9 PRINT CLEARLY NEW: RENOVATION: Li REPLACEMENT: i s PLANS SUBMITTED: YES [1 NO FIXTURES 1 FLOOR-9 BSM 1 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB am mum ma _____---------11------i - imasmameamommos CROSS CONNECTION DEVICE '11111.111.1.11111111.111111111.1111111111111 - :IIIIIIMIIMNIIIIIIIIIILIIXIIMRINIIIIIIIIIIIIIIIMIIII DEDICATED SPECIAL WASTE SYSTEM 1111111.11111111.11•11 DEDICATED GAS/OIL/SAND SYSTEM .111111MallialinIMMINallIMIRT-11— - -IIIIIIIIIIIIEjlli DEDICATED GREASE SYSTEM alal.11111Mall MUM 1111M111111111111111MMI DEDICATED GRAY WATER SYSTEM INIIIIMMIPON ---- 111110011111111ffiallaillail I'M DEDICATED WATER RECYCLE SYSTEM MOM 111KIMI111111111,111111111.111- 1"--- Mir 11111.IIIIIIIII DISHWASHER , j DRINKING FOUNTAIN --r- f ir -- 1---- 1 111111 11111611111 1-1 I=MOM FOOD DISPOSER 7 MIIIIIIIIIMIIIIIIIIINIIIMIIIIIIIIIIIUIINIIIIIIIIIIIIIMIIIIIIIIIIIIIIIINIIIIIIMMI FLOOR /AREA DRAIN ."----- ..10111111111111111.1 MAN IIITNIMIIIIN INTERCEPTOR (INTERIOR) ,_ r ,_.___ - ! .I - NM - I . KITCHEN SINK '----- , r- - i 1- ' 1110. ....... . • . LAVATORY - --- 1111111•M11111111111.111_111.1111111N.1II11N1III ROOF DRAIN MIN iamllm11.111111111111.1111111111111!-161M111m SHOWER STALL .1111111M N .1 i1,n1la1111t1im, 1lI. SERVICE n Ini 1l 1----'' venw.m.., me.,on....,•vm ,...., TOILET ____' 11111 URINAL 1- - IIIIIIIIIIIIIFM[-7 ---1 - - :, - - ''' --- "-- ------ 1---- _____ r--- -' WASHING MACHINE CONNECTION ' IINIMM ' 1 MIN NW misinsimumn WATER HEATER ALL TYPES INICNIIMMINI111111 •11. .111111111111111111M1111111.1111111111 ?-----"1 WATER PIPING 1111111111 - -1 r"---11 ' 111111111111111 fill i 11111S OTHER ' IIIIIIIINIAIIIIIIIIIIMMIIIIIIMIttallWMIIIIIIIIIIIIiMill11UMII 111111111.1111.11111111 1, -11- .111111111111111111111MINIIIIIIIIII 11.111111111111111111111111• r- 1 M111•11 INSURANCE COVERAGE: I have a current liabillinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Ei NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSJRANCE POLICY Et] OTHER TYPE DF INDEMNITY BOND [11 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 [j AGENT Li SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are truer 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 Iii7riwith II ertinerYpro' isior ,of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1—" — PLUMBER'S NAME STEPHEN WINSLOW LICENSE # i 12298 SIGNATURE M PrS:':1 JP iti CORPORATION Ei# 3-281C PARTNERSHIPLJ# LLCM1#I COMPANY NAME! E.F. WINSLOW PLUMBING & HEATING ADDRESS 18 REARDON CIRCLE CITY SOUTH YARMOUTH : STATE r MA ZIP [02664 : TEL 508-394-7778 FAX 508-394-8256 1 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 9,-, 'p Office of Investigations MIM1 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.® 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]** 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 41. 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: 1' -ply-- 12/01/2021 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.❑Board of Health 2.1=I Building Department 3.1=1 City/Town Clerk 4.DLicensing 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 �t- CITY YARMOUTH SOUTH MA DATE 2/4/22 =PERMIT# 2 2-- 94 Y, JOBSITE ADDRESS 1 AVERY LANE OWNER'S NAME ;JUDITH PAQUIN GOWNER ADDRESS SAMEN TE 508-398 8192 . FAX ____ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL LI EDUCATIONAL RESIDENTIAL sd CLEARLY NEW:= RENOVATION:ID REPLACEMENT:• %z PLANS SUBMITTED: YES NOLA APPLIANCES-1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ... BOOSTER I - _- . . v ----i CONVERSION BURNER €,x„ 1 1 T._ � `- ,.i _ - COOK STOVE �! x DIRECT VENT HEATER n 3.' ' if [ 3 DRYER FIREPLACE � �r _ _ __ FRYOLATOR 3 I'... , i 1 �1 [. . ...m FURNACE al `s . r----" GENERATOR iAI �mw 1 3 GRILLE 1 . . ._ INFRARED HEATER I 1.:. LABORATORY COCKS MAKEUP AIR UNIT r 1 .'r -[ 11 a a� OVEN 11— i POOL HEATER ti ., ROOM/SPACE HEATER r 1� ROOF TOP UNIT 'M ° >I 1 1= TEST ! , UNIT HEATER v € ;€ Al ;. 1 , __ 1 UNVENTED ROOM -EATER �, �1 1 't II 1€ i1 e I 1- ' WATER HEATER 1 OTHER,, --IF-0 v � --7' i 1 -1€ =Ir i[____I- 1 a INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE INDEMNITY 0 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 EJ AGENT ED 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 accurst 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 complian aJl'PP rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t`.r %1 • !i/..- Y PLUMBER-GASFITTER NAME LSTEpHEN WINSLOW LICENSE#1 12298 ' SIGNATURE MP D MGF Li JP 0 JGF 0 LPG[ CORPORATION 1,...j#IEEE��A PARTNERSHIP # - LLC #j ....... COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY [SOUTH YARMOUTH STATE MA ZIP[02664 liTEL 508 394 7778 FAX 3 508 394 8256 CELL N/A��ua jEmAIL.INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents —,7 T =� Office of Investigations Lafayette City Center " - 2Avenue 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 10.0 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.❑ Other *My 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 7 the jjbins and penalties of perjury that the information provided above is true and correct. Signature: /�' •�-�!^- 12/01/2021 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): 1.0Board of Health 2.0 Building Department 3.1=1 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia