The URL can be used to link to this page

Home My WebLink AboutBLDP-22-004437 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i CITY YARMOUTH MA DATE 2/9/22 PERMIT# BLDP-22-004437 JOBSITE ADDRESS 46 RAINBOW RD OWNER'S NAME DIBELLA ROSE C P OWNER ADDRESS 29 MORNINGSIDE DR ARLINGTON,MA 02174 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURES • 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 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❑ 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 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. 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 Slate Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Stephen Winslow LICENSE 1E298 SIGNATURE MP 0 JP 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8REARDONCIR 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 Na THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK WOiff Pi--: r 1 CITY 'YARMOUTH (WEST I MA DATE 102/05/2022 PERMIT # 21 - Li Li 3 JOBSITE ADDRESS 46 RAINBOW RD, W. YARMOUTH, MA 026731 OWNER'S NAME MIKE DIBELLA P , OWNER ADDRESS SAME TEL 304 358-0599 = FAX J TYPE OR OCCUPANCY TYPE COMMERCIAL 71 EDUCATIONAL —1 RESIDENTIAL El PRINT CLEARLY NEW: ' , . RENOVATION: REPLACEMENT: ✓V PLANS SUBMITTED: YES NOLv FIXTURES Z FLOOR—I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 11111111.111.1 ,, , f I i i CROSS CONNECTION DEVICE , i11 DEDICATED SPECIAL WASTE SYSTEM - .. € all Ma _..:__ DEDICATED GAS/OIL/SAND SYSTEM F 1.111111111111 f DEDICATED GREASE SYSTEM ® ¶ DEDICATED GRAY WATER SYSTEM r , 11111 DEDICATED +nrATER RECYCLE SYSTEM i 1 -11 •�I �u DISHWASHER I DRINKING FOUNTAIN __ FOOD DISPOSER _ 1I 'NM NM FLOOR /AREA DRAIN i _I INTERCEPTOR (INTERIOR) KITCHEN SINK 1,, 1 E` `` ' _ _ LAVATORY ,; 5= ROOF DRAIN SHOWER STALL ii. - - _SERVICE / MOP SINK ' _; ,`i TOILET , ! �_ -------i .±-,,,---,, _ . , ,„ 2-, 17- �. t. URINAL _ C MIMMIIIII — Mit WASHING MACHINE CONNECTION 1.1111111.MMINIMIIIMNIMINUMMI MIN MI[MOO NM WATER HEATER ALL TYPES E .. WATER 11 PIPINGSI OTHER ' ..... .,. �. UNE M. I. all @ _ .. .. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E.:71 NO Clj IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' v , OTHER TYPE OF INDEMNITY 1 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 r to 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 lia with II ertine pro)(isio2,of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW j LICENSE # 12298 SIGNATURE MP JP El CORPORATION `�#3281C PARTNERSHIP Li# LLCj# COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS n 8 REARDON CIRCLE ---__ Ili CITY SOUTH YARMOUTH STATE MA I ZIP 02664 TEL508-394-7778 _ FAX [ 98-394-8256 —10ELL N/A —I EMAIL 1iiECTlONS@EFWSLOwcoM The Commonwealth of Massachusetts Department of Industrial Accidents 1 Office of Investigations Lafayette City Center � ' 2 Avenue de Lafayette, Boston, MA 02111-1750 tz.'^` r= 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.JJ I am a employer with 99 _ employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/EEating 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.❑ 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 ins and penalties of perjury that the information provided above is true and correct. / 12/01/2021 Signature: 1' `''-.....- 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.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia