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HomeMy WebLinkAboutBLDP&G-22-004229 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK u fir'!{ CITY YARMOUTH ] MA DATE 1/28/22 PERMIT# BLDP-22-004229 r "r`fffi% JOBSITE ADDRESS 57 MAYFLOWER TERR OWNER'S NAME Glenn Maxwell P OWNER ADDRESS 57 MAYFLOWER TERR SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ NO❑ FIXTURES • FLOS)RS-. RSM 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 El 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 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 1Q298 SIGNATURE MP El JP El CORPORATION ❑l PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA 1 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 ❑ ❑ FEESS PERMITS PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK TA CITY YARMOUTH (SOUTH) pm MA DATE 1/20/22 1 PERMIT # 1 t ' k • JOBSITE ADDRESS 57 MAYFLOWER TERRACE OWNER'S NAME GLENN MAXWELL OWNER ADDRESS ; SAME TEL 508 272-6060 FAX F-- - - ---' TYPE OR OCCUPANCY TYPE COMMERCIAL ri EDUCATIONAL ri RESIDENTIAL ri PRINT CLEARLY NEW: . RENOVATION: REPLACEMENT: = PLANS SUBMITTED: YES El NOD FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 i 7 8 9 10 11 12 13 14 BATHTUB I` W IMRE CROSS CONNECTION DEVICE H rMIN NMI :: MIN NMI 111111111101111 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM :.. . . .IIMMIlainriall INIMIMIIIINIMION DEDICATED GREASE SYSTEM M DEDICATED GRAY WATER SYSTEM 11111.1111111411M111,111111111111.111 11.11.1111 all MR.1111.101.1111111N DEDICATED WATER RECYCLE SYSTEM ' DISHWASHER .............. 9 .. .w ._:.. .,. .� r .._ DRINKING FOUNTAIN I °r r _ ulin. ni FOOD DISPOSER .... W- .. FLOOR I AREA DRAIN -aaltainieIMMIIMIMIIII.alli=aalIllIllitai10IMIIIIIISilaillM INTERCEPTOR (INTERIOR) KITCHEN SINK _..__ LAVATORY . -:"1 "---i --. - ' ROOF DRAIN _ _ , _ 7:- `MUNE —1111111 .11111111.1111111111 SHOWER STALL 1 E4[`} 3 4E a SERVICE / MOP SINK Jir — w.. r TOILET ::... . I a:. y URINAL ...W ' — ,W.. ._ �... 1' _ WASHING MACHINE CONNECTION IMMOMMINIMMII INN. 1 k MO MM.. WATER HEATER ALL TYPES 1111011MINMINIMANI.1111111111MIMMINIMISTITIWINIIMIIM1 WATER PIPING w ..w.._... ...._,........_... M1111 OTHER ` n ... ,NMII ..1111M�. ram^ ..,. >x,. MN ....... 11.11N81.1 ... 11111 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 ; i 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. CHECK ONE ONLY: OWNER 11 AGENT 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 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 Ii with 11 ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LSTEPHEN WINSLOW 1 LICENSE # 12298.,_ 1 SIGNATURE MP, JP 81C CORPORATION # 32 PARTNERSHIP# LLCL# COMPANY NAME E.F. WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE [11 MA ZIP 02664 TEL 508 394 7778„ . . ,,...H . FAX '508-394-8256 ' CELL ' NIA EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents z _ Office of Investigations ,M._eal 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.❑ 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 ' el the and penalties of perjury that the information provided above is true and correct. ,f/ ` / 12/01/2021 Signature: Y '` 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.❑City/Town Clerk 4.0 Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 'January 28,2022 I PERMIT# BLDP-22-004229 JOBSITE ADDRESS 57 MAYFLOWER TERR OWNER'S NAME Glenn Maxwell G OWNER ADDRESS 57 MAYFLOWER TERR SOUTH YARMOUTH MA 02664 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES❑ 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/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 0 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 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-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP©MGF 0 JP❑ JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL insoectionsnefwinslow.com S31ON M3IAR1 NVId #±I VJeHd $ :333 ❑ ❑ 1IIN213d 3H1 SV S31183S NOIlVOIlddV SIHI oN seA S310N NO1103dSNI l`dNId AlNO 3Sfl b0103dSNI Ji0d 30Vd SIHJ S310N NOI103dSNI SVO HJl021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK f CITY YARMOUTH (SOUTH. MA DATE i.1/20/22 PERMIT # z - 2 `1 :i��v».»,Oa<aa,ihvv.»tvtta.aM\A\\WUaal.l�„ Vi.U�,S \t,,t,.lA\WU,6'wys,W,,,,g*\F\F:S'id.,a,,,,( ..��.4., C�G�,,,, AY dd..cu.a:. Y JOBSITE ADDRESS 57 MAYFLOWER TERRACE OWNER'S NAME GLENN MAXWELL G . OWNER ADDRESS SAME TEL 508 272 6060 JFAXLaq TYPE OR M OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ' RESIDENTIAL PRINT CLEARLY NEW: RENOVATION REPLACEMENT: 1 v PLANS SUBMITTED: YES 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 DIRECT VENT HEATER DRYER FIREPLACE lt......u.. . FRYOLATOR FURNACE ::::Etitil,,W ...... .etkr,„at:A:. t4 caw 4 GENERATOR • GRILLE INFRARED HEATER • LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT _ TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER :: .w. :: .... '5 :...ua...... i.:.::.... :�smmuseae,44.aMwe»aea����a�**%,44*auwaa\c44r���a��\aa�ts::. sr.'tte.,mm;.; N, tsoxeawwa cmasuanm\oac.,,,,4nca.ca .uc a..,s,..,,,,,,, ..M..a.. »ate..:.,:.,... INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES !-" NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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 AGENT 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 a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General laws. ......41,/Loa." PLUMBER-GASFITTER NAME i STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP »„ » MGF ,,,h JP JGF , LPGI ,.: j CORPORATION =.�c # 3281C PARTNERSHIP # �ar �ama� V LLC #` COMPANY NAME: E F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE71 � . ..« na.ik�u ..< :.n. , �.a _:, :«u.:.a m m:a m«A«« Qa CITY SOUTH YARMOUTH STATE L MA ZIP'02664 JTEL98394J778 FAX 508 394 8256 CELL= N/A EMAIL INSPECTIONS@EFWINSLOW.COM Nn,.cxcz�S rnx c:ma n.S. ISM xa.:UMNdit'aa a�"w'.a aacaw�au\ xa" ia\acauu�a\;armwaca ai uwwmx�`a.;ao\aar\a\a wwoaaza ,V., The Commonwealth of Massachusetts Department of Industrial Accidents 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): 1.50 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.D. 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.❑ 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 ' of the 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 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia