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Home My WebLink AboutBLDP-22-004306 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - .: CITY YARMOUTH ] MA DATE 2/3/22 PERMIT# BLDP-22-004306 r1 JOBSITE ADDRESS 25 JACQUELINE CIR OWNER'S NAME TEATOM ROBERT J P OWNER ADDRESS TEATOM ELIZABETH STONE 25 JACQUELINE CIR WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES • FLOORS-I 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 1 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❑ NO El IF YOU CHECKED YES,PL EASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Cl 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 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 ❑ ❑ FEES S PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH I MA DATE 1/26/22 PERMIT # JOBSITE ADDRESS 25 JACQUELINE CIRCLE W YARMOUTH I OWNER'S NAME ROBERT TEATOM POWNER ADDRESS SAME I TEL 5087719307 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL El PRINT CLEARLY NEW: Il RENOVATION: El REPLACEMENT: ❑ PLANS SUBMITTED: YES 0 NOD FIXTURES Z FLOOR BSM 1 M 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ IIM 1 IIIIIII illil CROSS CONNECTION DEVICE _ W___!M!ME MIMI. DEDICATED SPECIAL WASTE SYSTEM NM MI M 1111.1 ME FWIMIIIIIIIII ii DEDICATED GM/OIL/SAND SYSTEM F-M Will MI IMIE-1111111C-1 n, .... am DEDICATED GRAY WATER SYSTEM1 MR IIMI M-1_ 1 DEDICATED WATER . MB MiiiiMMiii MINI am . DRINKING FOUNTAIN 1 IIIIIIMMI M 1-- _ liM r_____. MI _ in ' _ LAVATORY ill.= ROOF DRAIN in Ell — GM 11111111M FOOD DISPOSER , SERVICE / • IIIIIIMIMIIIIWIOIIIIIIBMIN—MIMEIIMIPMIIIII.J- TO —�IIIIIIIIIIIIIIII URINAL Warli_MIMI - WMHING MACHINE CONNECTION _—IIII —_11101111111111111 WATER ' OM �. Em---al WATER PIPING 1.11 Mil - MilliMME1111 li MANI • i----mmumunma MN _1111_ 111111=1111111.1110.111 illation!.- .1111111MMI II INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES El NO Ej IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY L I BOND DI 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 0 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 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 li with 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 El CORPORATION El# 3281C PARTNERSHIP®#M. LLC❑# r- o COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE -- 1 k' CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM ; S\ The Commonwealth of Massachusetts A Department of Industrial Accidents fli) i t Office of Investigations Lafayette City Center t 2 Avenue de Lafayette, Boston,MA 02111-1750 s..' 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.Ill I am a employer with 90 employees (full and/ 5. ❑ Retail or part-time).* 6. 0 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]** 11.❑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:01/01/2022 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 I 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 I do hereby cer the in and penalties of perjury that the information provided above is true and correct. 0 Y i(/ "-- - Date: 01/02/2021 I 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 LjBoard of Health 2.0 Building Department 3.❑City/Town Clerk 4.El Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia