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HomeMy WebLinkAboutBLDP&G-22-002204 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 10/18/21 PERMIT# BLDP-22-002204 kis== t-�= JOBSITE ADDRESS 27 TOURAINE WAY OWNER'S NAME MATAMOROS LIBIA N tv P OWNER ADDRESS C/0 LIBIA MCAULIFFE 27 TOURAINE WAY SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El 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 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 ❑ 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❑ 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$ PERMIT PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK eil �= CITY YARMOUTH (SOUTH) MA DATE 10/14/21 PERMIT # j z Z`'t ti/r ...,,._,_._ JOBSITE ADDRESS t27 TOURAINE WAY OWNER'__ ___S NAME'LIBIA MCAULIFFE ...I „,,, ______ _______ _. ____ __ OWNER ADDRESS SAME TEL 508-394-3924 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL k ; EDUCATIONAL _.y1 RESIDENTIAL i_.. . PRINT CLEARLY NEW: 171 RENOVATION: ' I REPLACEMENT: PLANS SUBMITTED: YES 0 NOH FIXTURES 7. FLOOR---* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB OM nal NMI WI CROSS CONNECTION DEVICE II1 3 _ . I ___I DEDICATED SPECIAL WASTE SYSTEM Maw hll11 !1I _ . 11 I II DEDICATED GAS/OIL/SAND SYSTEM 01111111111 111111 111111M11111111.111111111IMO NW IMIIIIIIIIMOINIIIM DEDICATED GREASE SYSTEM IIIIIIIIWIII IIIIIIMMITOMIIII.111111111111111111111111111111.1 l DEDICATED GRAY WATER SYSTEM ingiam DEDICATED WATER RECYCLE SYSTEM j i ,, 'r_. �a... .. _ # v:z _ [_ _J . 111111111111111.1 DISHWASHER , i DRINKING FOUNTAIN OWN IIIIIIIIIIIIIIIIIIIIIIIIIIIIMIONNIIIIIMIliiiIIIIMIIIIIMINIMI FOOD DISPOSER I ,' FLOOR 1 AREA DRAIN l 1 _,, _�o '61111101 1 € INTERCEPTOR (INTERIOR) ' _,._._. .1 .�___I . � . �t . _ ' ___ L_..__ ..- .-- , ,_ fr ''! WIN --. KITCHEN SINK _._ _ I _.._ _ l �? _�` _ ` I LAVATORY iI i l I . ROOF DRAIN ' _ I M O,. _ SHOWER STALL rainIIf ..: . ........ .........:: I SERVICE / MOP SINK _ .. ! 1 TOILET _ ,i 11-_ . .. . ,I . . . . _ - 1 Ir ,, aili URINAL ! mu. .... . WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 I9# 1'.-.. _ iiiiiiin ,II. 1 ....w. :. °! , WI WATER PIPING I il - - OTHER -. m.. .. .... 1 Hiii 11.1.0112.1.11111111m1. IINIMIMIIIIIINIIINIIIIMIMIIIIMIFOMIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMINIIIIIIIIIIIIIMIIIIIIIIIIIIIWFMFEIIIIIIIIMNI 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, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v 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 .�._I AGENT ii 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' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - PLUMBER'S NAME STEPHEN WINSLOW 1 LICENSE # 12298 SIGNATURE MP , JP 1 COR.. .PORATION I____iI# 3281 C PARTNERSHIP FA# LLC #L __ ___.....COMPANY NAME ' E.F. WINSLOW PLUMBING & HEATING ADDRESS 1iARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 ¢_ __ 1 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 99 . , ,f Office of Investigations Lafayette City Center 1'' 2 Avenue de Lafayette, Boston, MA 02111-1750 _/ M- , � wwn.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 90 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 off .s 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 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 perjwy that the information provided above is true and correct. Signature: Y ^�°'`^-� Date: 01/02/2021 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.❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.1=1Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I CITY YARMOUTH MA DATE October 18,2021 PERMIT# BLDP-22-002204 Isi= f 3IT JOBSITE ADDRESS 27 TOURAINE WAY OWNER'S NAME MATAMOROS LIBIA N G OWNER ADDRESS CIO LIBIA MCAULIFFE 27 TOURAINE WAY SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER 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-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 1026641207 I TEL I FAX CELL 1 1 EMAIL linspections a(�efwinslow.com S310N M31A3a NVld #iIINa3d $ 33H 11M3d 3H1 SV S3AN3S NOI1V3IlddV SIHL oN saA S310N NO1103dSNI lVNId AINO 3S1210103dSNI JIDA 3OVd SIH1 S310N N01103dSNI SVO HDfOa MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7ral 5w su - fa CITY 'YARMOUTH (SOUTH MA DATE 10/14/21 I PERMIT # Z ? 2 2- JOBSITE ADDRESS 27 TOURAINE WAY OWNER'S NAME LIBIA MCAULIFFE OWNER ADDRESS SAME I TEL508 394-3924 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO 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 FRYOLATOR FURNACE I GENERATOR GRILLE INFRARED HEATER j LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER l OTHER - 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 r4 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 a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME [STEPHEN WINSLOW I LICENSE # 12298 SIGNATURE MP MGF JP 3... JGF LPGI CORPORATION v # 3281C PARTNERSHIP LLC #. COMPANY NAME: E F WINSLOW PLUMBING & HEATING ADDRESS [ 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE I MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents P ' Office of Investigations (.. ,_ - Lafayette City Center '� 2 Avenue de Lafayette, Boston, MA 02111-1750 =t g..;` wwx.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): 1.11] I am a employer with 90 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. 0 Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0Health 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 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 perjuty that the information provided above is true and correct. ' / 01/02/2021 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 2.1=1 Building Department 3.❑City/Town Clerk 4.['Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia