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HomeMy WebLinkAboutBLDP&G-22-003667 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK kr ,�, CITY YARMOUTH MA DATE 12/30/21 PERMIT# BLDP-22-003667 c JOBSITE ADDRESS 14 BRADFORD RD OWNER'S NAME WETHERBEE CHARLES B P OWNER ADDRESS 14 BRADFORD RD WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURFS 1 FLOORS—. RSM 1 7 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND 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 0 NO 0 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 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 I EMAIL linspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ El FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK l �F id..•. I ........:..... a!SIA11 - CITY YARMOUTH (WEST) MA DATE 12/21/21 PERMIT # ZZ' CD�' JOBSITE ADDRESS 114 BRADFORD ROAD OWNERS NAME CHARLES WEATHERBEE OWNER ADDRESS SAME ITEL 774-487-1674 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 1 EDUCATIONAL Ij RESIDENTIAL E. PRINT CLEARLY NEW: . _.? RENOVATION: __. REPLACEMENT: j PLANS SUBMITTED: YES . NO FIXTURES Z FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB - _ CROSS CONNECTION DEVICE I" iri ' �_ _..DEDICATED SPECIAL WASTE SYSTEM line ! 1° '- , - ' i DEDICATED GAS/OIL/SAND SYSTEM ` ` _ . .n _ DEDICATED GREASE SYSTEM 1 I _ I ll DEDICATED GRAY WATER SYSTEM I 53 _ __ _____ _ .. . . i, ‘ _ F____ DEDICATED WATER RECYCLE SYSTEM j , , _--4 „...... , D I SH1,^.�ASH E R i�-...=.. ..._ ._ f r l DRINKING FOUNTAIN __.1 , _ �I a _ 1 '1--- -1 1- - -1 FOOD DISPOSER FIMIMINIIIIIM-11-Mlin 1111111011111111.111111111111111 MIN Mlilliallillillell FLOOR /AREA DRAIN hi 1 .._._.... Ie I a III INTERCEPTOR (INTERIOR) IIIIIIIMIIIRIIIIMIIIIIMI MN[INIIIIIIIIIIIIIN 11111.11111111111111111111111111111111M KITCHEN SINK LAVATORY I. _ .1_.. ...._.. NMI MN IIIMIIIIIIMIIIIIIIIIBIIIIIIIIIIIMIMMIPMI ROOF DRAIN SHOWER STALL MINIIIIM111111110 MIN 1111.11MOUNIIIIIMINIMIIIIIIIMIIIIIIIIIIIII 1.11WIIMIIIMIIIIIIIIIIIIIIIIIIIIIIIIIIMMIIII URINAL i r ma MIA ,, , 611111.-Mr ,1 ..,..1,,,f _ 11 WASHING MACHINE CONNECTION imimaimaisr6111111111F611111111111111111Iiiiimi imir- imiiiiimulin. WATER HEATER ALL TYPES WATER PIPING I- _ j 1 "t ' '.) ru. OTHER v . I l° d' y _ _i } i . 1 r-------'- !II __ 11 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES U NO L___1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Li 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 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 lia with II ertine pro' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP S ij JP —I CORPORATION E# 3281 C PARTNERSHIP 1# ] LLCE # W COMPANY NAME I E.F. WINSLOW PLUMBING & HEATING I ADDRESS [8 REARDON CIRCLE CITY [ ouTH YARMOUTH STATE MA ZIP 02664 TEL Fiô8-394-7778 FAX 508-394-8256 CELL N/A EMAIL [1SPECTIONS@EFW!NSLOWOOM The Commonwealth of Massachusetts Department of Industrial Accidents 99Office of Investigations P. Lafayette City Center 2Avenue de Lafayette, Boston,MA 02111-1750 M t-✓ 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 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.❑ 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 ' e the 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): 1.111Board of Health 2.1=I Building Department 3.0 City/Town Clerk 4.❑Licensing 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 >P—. tn—. CITY YARMOUTH MA DATE December 30,202'PERMIT# BLDP-22-003667 JOBSITE ADDRESS 14 BRADFORD RD OWNER'S NAME WETHERBEE CHARLES B G OWNER ADDRESS 14 BRADFORD RD WEST YARMOUTH MA 02673 TEL TYPE,OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES❑ NO❑ 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 I 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 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-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP©MGF❑JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(aefwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r— _tima��� CITY YARMOUTH WEST MA DATE 12/21/21 PERMIT # L 3(�!v JOBSITE ADDRESS 14 BRADFORD ROAD OWNER'S NAME CHARLES WEATHERBEE GOWNER ADDRESS SAME TEL 774-487-1674 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ` RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: i 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 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER _ .. ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER F WATER HEATER OTHER I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES i 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:wv a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 0 . PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE #' 12298 SIGNATURE MP i MGF 1_,,,„,,i JP JGF I LPGI .. CORPORATION i # 3281C PARTNERSHIP # LLC Lii# .: COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE ,,,,,wxatadY- . cu _s__,,„ :3.....,i,hx+¢.G£'iu"!_,.. .n.:i...,, ,, .,,.x.,,,,,,w.,W.aern,.:.,4,,,,,,,..; ... .... ae..12.3d4ANFf66Fhadka£M ' CITY SOUTH YARMOUTH STATE MA ZIP 02664 'TEL 508-394-7778 FAX 508-394-8256 CELLS N/A EMAIL INSPECTIONS@EFWINSLOW COM The Commonwealth of Massachusetts Department of Industrial Accidents 9 , +9 Office of Investigations Lafayettet City Center / 2 Avenue de Lafayette, Boston,MA 02111-1750 e Fy swww 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): 1.111 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. Li 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.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.111 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. L 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 "�-�n��th�wis�^d penalties of perjury that the information provided above is true and correct. `2 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❑Board 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