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HomeMy WebLinkAboutBLDP&G-22-004237 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .9a CITY YARMOUTH MA DATE 1/28/22 PERMIT# BLDP-22-004237 JOBSITE ADDRESS 44 WINDING BROOK RD OWNER'S NAME HERRING CARTER D P OWNER ADDRESS HOLMES LISA M 44 WINDING BROOK RD SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES NO❑ FIXTURFS FLOORS—. 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❑ 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 1Q298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 18 REARDON CIR CITY S YARMOUTH STATE MA ZIP 1026641207 TEL FAX CELL 1 EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El El FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CA�, CITY YARMOUTH I MA DATE 1/21/22 PERMIT # 2— 'Z 3 ft,ttJOBSITE ADDRESS 44 WINDING BROOK RD S YARMOUTH 1 OWNER'S NAME LISA HOLMES POWNER ADDRESS SAME TEL 5083987978 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL 7 EDUCATIONAL [1 RESIDENTIAL Fl PRINT CLEARLY NEW: E RENOVATION: ❑ REPLACEMENT: 0 PLANS SUBMITTED: YES ❑ NOQ FIXTURES 1 FLOOR--' BSM 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ENEN MI CROSS CONNECTION DEVICE F (( DEDICATED SPECIAL WASTE SYSTEM Kh � j DEDICATED GAS/OIL/SAND SYSTEM En WI 1h mg mg WIC 111111111.11111.1 DEDICATED GREASE SYSTEM num MIME= um um me MIIIIIIIIMIMOR NM ME DEDICATED GRAY WATER SYSTEM 1WIIIIIM DEDICATED WATER RECYCLE SYSTEM [ MIMI DISHWASHER 111111111111111111111111111M 111111111 INN aniaillimi DRINKING FOUNTAIN =MITINT ow ma F F--- - , - witrigiimm FOOD DISPOSER 111111111111111111111WINIFINIFINII FLOOR I AREA DRAIN iiiiiminiumenumnimillill FI INTERCEPTOR (INTERIOR) h111111111111.0111111111111111111.11 KITCHEN SINKiiiiiih LAVATORY ••.• Ii —TIam ROOF DRAIN MilillEKINEINNIIIIIIM mg Imm IIM. SHOWER STALL I !111111.11 SERVICE I MOP SINK == IM,11.11111.111111M TOILET mg Buciligiimiumum Elm!nolliino millIIIIII M. URINAL wirommiiiiiip111111.1111Mmon ImENTWIIIMMI WASHING MACHINE CONNECTION MMIIIIIIIIMEOM OM M WATER HEATER ALL TYPES 111111iiiiiM mum MI Ill.NE Ern ma EN NW= L WATER PIPING INIZIIIIMM Illn!..1 I on ; �I OTHERIIIII an MIR i EE 11111 11.1 M NE(WIN11111.111111111111111111111111111111111111111111111111111.11111 IEEPIINEIIIINIIIIIIIIIIIINIIIIMIIINIIINIIIIIIIIIIIIIIIIIIIIIIIMIIIIIMIFIIIIIIIIIIIFIIIIIIIIIEIIIIFIIIFIIIII INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [ NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 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. CHECK ONE ONLY: OWNER 0 AGENT `4:=. 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 II ertine proxisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,A -4..4,' `r PLUMBER'S NAME I STEPHEN WINSLOW LICENSE # 12298 SIGNATURE `-g' MPD JP ® CORPORATION[]# 3281C PARTNERSHIPQ# LLC©# r -r' COMPANY NAMELF. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE �. CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 1508-394-8256 ] CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts _ Department of Industrial Accidents ic) --.1.,1— 96—,, ' Office of Investigations =E.i.— `1 Lafayette City Center A( -" =,i 2 Avenue de Lafayette, Boston,MA 02111-1750 N44—:.''j 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 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. ❑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 *My 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 •3 ...�the ins and penalties of perjury that the information provided above is true and correct Signature: 0 ~- (• 01/02/2021 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): 1fBoard of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia p\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a BLDP-22-004237 fir j� CITY YARMOUTH � MA DATE January28,2022 PERMIT# JOBSITE ADDRESS 44 WINDING BROOK RD OWNER'S NAME HERRING CARTER D G OWNER ADDRESS HOLMES LISA M 44 WINDING BROOK RD SOUTH YARMOUTH MA 02664 1 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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/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❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX —1 CELL EMAIL inspections anefwinslow.com 8310N M3IA321 NVId #111,1213d $:332 ❑ 0 111'0nd 3H1 SV S3Ad3S NOI1V011ddV SIHl oN saA S310N NO1103dSNI 1VNId AlNO 3Sl 210103dSNI 210d 3OVd SIH1 S31ON NO1103dSNI SV0 HJl0H MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK II w..TitiTZ .;- yti= CITY �YARMOUTH I MA DATE 1/21/22 I PERMIT # _ W JOBSITE ADDRESS 44 WINDING BROOK RD S YARMOUTH I OWNER'S NAME LISA HOLMES 1 OWNER ADDRESS SAME _ TE 5083947978 FAX J. TYPE OR OCCUPANCY TYPE COMMERCIAL1 EDUCATIONAL RESIDENTIAL DI PRINT --- CLEARLY NEW:Ej RENOVATION: REPLACEMENT: El PLANS SUBMITTED: YES El NO E] APPLIANCES -1 FLOORS--* BSM 1 2 3 4 5 6 7 8 9 10 11 j 12 13 14 BOILER BOOSTER '. CONVERSION BURNER ; „...-3, COOK STOVE _O- i+.., DIRECT VENT HEATER �_ _ DRYER r ,.--, FIREPLACE FRYOLATOR , - FURNACE J __ _.__- GENERATOR _ � _ ,. GRILLE .. I T_ INFRARED HEATER _f in— .� LABORATORY COCKS T .� _ MAKEUP AIR UNIT 1. 'II____. o OVEN . r•---- - POOL HEATER _ _ � _ -_ ROOM / SPACE HEATER �: - I _ ROOF TOP UNIT �� — — n *- TEST - - _-- .� _ _ �_ _ UNIT HEATER .__. , __ . . _ .1111111 UNVENTED ROOM HEATERy WATER HEATER _ �. :,_. . . OTHER , r r.. _ ._ C,.,_.___-„r_,.._.___..a,,.... L _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Li NO L.., I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY EJ OTHER TYPE INDEMNITY 1 = BOND L 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 i a P rtine provision of the — Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (/ r --- ......"—..— PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE #[12298 SIGNATURE �, MP _� MGF Ej JP IDJGF El LPG,® CORPORATION Q# 3281C PARTNERSHIP O# LLC ❑# COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING I 0 ADDRESS 8 REARDON CIRCLE lam" CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 N a- FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts �t Department of Industrial Accidents ft `: Office of Investigations Lafayette City Center ' ir , 2 Avenue de Lafayette, Boston,MA 02111-1750 -,`'M,.•'„ 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 90 employees (full and/ 5. ❑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. [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 *My 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 ce ' er the ins and penalties of perjury that the information provided above is true and correct. ,/ 01/02/2021 Signature: {"' . <11,--- 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): 1fBoard of Health 2.❑Building Department 3.❑City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia