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Home My WebLink AboutBLDP-21-002547 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i CITY YARMOUTHtot MA DATE 11/5/20 PERMIT# BLDP 21 002547 JOBSITE ADDRESS 69 ICE HOUSE RD OWNER'S NAME MURRAY MARY I P OWNER ADDRESS 16 LENOX PL SCARSDALE,NY 10583-7211 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑� PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESD NO El FIXTURES z FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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 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 0 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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 142298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# I COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 1026641207 I TEL I FAX CELL I I 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 FOR A PERMIT TO PERFORM PLUMBING WORK CITY „r_r..`(,01 t_ 1, _______., ; MA DATE 2 _ PERMIT# a bi :;I--/ 'c0,,?S\' 7 JOBSITE ADDRESS ' U Z 6644 0 _ << -- _._S J .. _ ��tr Dv OWNER'S NAME t ;Ji ' At4 a /gni/ j P .77-OWNER ADDRESS e �-C�✓. r � _. .:e.`? _ . TE ;/5 _._,._._ .- 37 ]FAX L.,,..„. TYPE OR OCCUPANCY TYPE COMMERCIAL (� �� PRINT EDUCATIONAL f_�j RESIDENTIAL CLEARLY NEW: [ RENOVATION: [l REPLACEMENT: '- PLA NS SUBMITTED: YES Li N0 FIXTURES Z FLOOR-0 BATHTUB 3 4 5 6 7 8 9 10 11 12 13 14 CROSS CONNECTION DEVICE ' F II— r—T DEDICATED SPECIAL WASTE SYSTEM "� int �_� I� _ - EDICATED GAS/OIL/SAND SYSTEM r �_-_ ,i i ar— n DEDICATED GREASE SYSTEM II., _ ..,_ r- , DEDICATED GRAY WATER SYS TEM MO ' 777 - DEDICATED WATER RECYCLE SYSTEM � I � _ -- :, i ;1 ----M IllintaNsuldOrini �DISHWASHERI i - • r__ 11111L........1--.1 -7 - _- "MlttIIIIIIMFM--HNIITr--7- FOOD DISPOSER 11.01111,_ 11111111-111.,:7_,Mit ft FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) ( " M KITCHEN SINK _ _._. .�:: LAVATORY ------ ROOF illifliiI"alla SHOWER STALL i ---- M(R.111M7TOILET rURINAL • Mi_ _..7M-11, _—,. _ ? WASHING MACHINE CNNECTION I _ � ' WATER HEATER ALL T . . . L - '1111111111MIMNIMMINIMUMIIIIIINUTIMINIMININIFIC-7 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MG C h. 142. YES IF YOU CHECKED YES, PLEASE ►NDIC.eTE T ,- NO ! ""� HE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELO,tI LIABILITY INSURANCE POLICY L i OTHER TYPE OF INDEMNITY l __j 1 NOVOWNER'S INSURANCE WAIVER: BOND [ . NOV 4 2020 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 ives this requirement. l Bu`Ll.)"v" �4_ ___:_NT <,' CHECK ONE ONLY: OWNER [. La AGENT ++a `^ SIGNATURE OF OWNER OR AGENT ' I hereby certify that all of the details and information I have submitted or entered regarding this application are and that all plumbing work and installations performed under the permit issued for this applicationp will be in co li wit r ll te ertine to the b st roo's oy of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. p Y� PLUMBER'S NAME I STEPHEN WINSLOW ILICENSE # fr '""` .•��112298 I SIGNATURE s' MP _�..1 JP CORPORATION ;#I 3281C iPARTNERSHIPO# COMPANY NAME LE.F. WINSLOW PLUMBING & HEATING I ADDRESS k REARDON CIRCLE SOUTH YARMOUTH — CITY �` 1 !STATE MA ZIP 102664TEL 508-394-7778 '� FAX 1508-394-8256 CELL ( NIA J EMAIL INS�, The Commonwealth of Massachusetts • Department of Industrial Accidents Office of Investigations '' Lafayette City Center 2 Avenue de Lafayette,Boston,MA 02111-1750;,� wwwmass.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. 0 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. g ❑Non-profit [No workers'comp.insurance required] 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#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.#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 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' e the ins/and penalties of perjury that the information provided above is true and correct. Signature: 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): 10Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: