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Home My WebLink AboutBLDP-21-003282 I— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,_' cs CITY YARMOUTH MA DATE 12/9/20 PERMIT# BLDP-21-003282 ' t{ = JOBSITE ADDRESS 19 BARKENTINE CIR OWNER'S NAME JOHN VAILLANCOURT P OWNER ADDRESS 19 BARKENTINE CIR SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑v PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO El FIXTURES z 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 1 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 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 0 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#2298 SIGNATURE MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX 1 I 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 FORA PERMIT T Jy 7-c, 0 PERFORM PLUMBING WORK =:=u�l�;� CITY ::3I ::::-:i----- _MA DATE a ). ,y. LW I PERMIT#�o P'v7/"� 3Z JOBSITE ADDRESS ��,rBSIT�� (,� ; ,,'„ U1 OWNER'S NAME _Jo. (Lila /l4n(0/4 J POWNER ADDRESS SL.A. 4 ' t� 12- ' TYPE ORw _ , .._ _ TEL 3 3 S 6 y_y,_ w' FAX OCCUPANCY TYPE COMMERCIAL f EDUCATIONAL N AL PRI ..NT �_:� RESIDENTIAL (r- CLEARLY NEW: Li RENOVATION: , REPLACEMENT: PLA NS SUBMITTED; YES E NOE, FIXTURES Z. FLOOR--4 BSM 1 2 3 4 5 6 7 8 BATHTUB I 9 10 I 11 12 13 14 CROSS CONNECTION DEVICE �_ - . . ,1 _ 1[ L. 11 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYS TEM domain 'f " � - wLomm-- DEDICATED GREASE SYSTEM � :� �- - . i.,,�,� - �� DEDICATED GRAY WATER SYSTEM _�v ' ----, �� ! DEDICATED WATER RECYCLE SYSTEM + ,� it I t DRINKING FOUNTAIN DISHWASHER imil � - - �� FOOD DISPOSER 1.111.. � � I -.: ..- .:I. . �_._�� . .; .h . _ �I min= FLOOR/AREA DISPOSER RAIN I � M !' INTERCEPTOR (INTERIOR) KITCHEN SINK III � ± 1_. . ._ LAVATORY w,., - -- - i I r::.. - - �; mums —_ ifirtlitiil ROOF DRAIN __ _ __ {: ___ - - .IIIIMMIIIIIIIIIII SHOWER STALL - 1 I i 111111111 SERVICE / MOP SINKi _.. _ _6 _.___. r TO 1 ItIIIIIIIIIIIIIIII URINAL . . --- -- imi WASHING MACHINE CONNECTION -- --- - �' _ -liillianinilli �l WATER HEATER ALL TYPES �._..� - - - I _I -'----:- - ��- - t I WATER PIPING allit ', ` _ IIIII - .., I OTHER - l IT urri _ _ _ .«z ems_ 'r-- f+ _ i.` miginag i .. r r -_.w.�..., -- �kluy`�cbbi ��-- F�,t' - 1 ___11__ _ i I • on aim 1] - i. I I, it r �t INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MG Ch. 142, YES f NO Li ° r IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - LIABILITY INSURANCE POLICY v OTHER TYPE OF INDEMNITY [I BOND ey. -� `�' " 1T: . 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 L I AGENT El SIGNATURE OF OWNER OR AGENT I hereby certify that ell 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 11 wit II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW ]LICENSE # 12298 SIGNATURE MP JP[ CORPORATION ij# 3281C PARTNERSHIP[# _ _ COMPANY NAME E.F. WINSLOW PLUMBING & HEATING J ADDRESS f 8 REARDON CIRCLE j } CITY[SOUTH YARMOUTH STATE MA I ZIP 02664 " TEL 508-394-7778 C ) \.r` Q- FAX 508-394-82561 CELL N/A EMAIL INSPECTIONS@EFWINSLOW,COM 3 The Commonwealth of Massachusetts moo= Department of Industrial Accidents > Office of Investigations r mel�tli=J 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.alI am a employer with 90 employees(fiill and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 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 area corporation and its officers have exercised 9. 0 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 01 must also fill out the section below showing their workers'compensation policy information. **1f 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.Lie.#1909A Expiration Date: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 o.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' ee the ins and penalties of perjury that the information provided above is true and correct. Sianature: /Y""` �-^ 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): 1CiBoard of Health 2.0 Building Department 30 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: