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HomeMy WebLinkAboutBLDP-21-001158 A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK q CITY YARMOUTH MA DATE 913/20 PERMIT# BLDP-21-001158 I' J08SITE ADDRESS 2116 HEATHERWOOD OWNER'S NAME BEAUDREAU ELIZAVETHA TR P OWNER ADDRESS CIO MARK SANTOS P 0 BOX 554 CUMMAQUID,MA 02637 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL E PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES a FLOORS—n 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 1 ROOF DRAIN SHOWER STALL 1 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 State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Stephen Winslow LICENSE 12298 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY IS YARMOUTH I STATE MA ZIP 026641207 TEL FAX I CELL 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 n FEES$ PERMIT# PLAN REVIEW NOTES &\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK VEWiiti CITY1_141(41,0-14_ T_ MA DATE I / / f i I PERMIT# (3t 7-2l -W I tS4 JOBSITE ADDRESS �-11(�Nr_ 1 1ti;L ,e(,) ��c,tif�� it A _� OWNER'S NAMEL i t\Ce Rah i' 0�1 Co .V � I � L_____cam_<___ �, �R„�.__._.. ' TEL � G?"L l��S ?.�..-kFAX��a�..OWNER ADDRESS �. _ p TYPE OR OCCUPANCY TYPE COMMERCIAL 7, EDUCATIONAL Li RESIDENTIAL _ PRINT PLANS SUBMITTED: YES __ NO �_I CLEARLY NEW: -----( RENOVATION: 0 REPLACEMENT: ( " FIXTURES 1- FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 -ME BATHTUB ._.__ I_________ L— CROSS CONNECTION DEVICEME I P '� -- ' DEDICATED SPECIAL WASTE SYSTEM i � DEDICATED GASIOIL/SAND SYSTEM ___-_._.�` .. __ __ ,, 1 I- - - --' DEDICATED GREASE SYSTEM ' _ , _ - — [---___ ,-----„N DEDICATED GRAY VIATER SYSTEM ____ _.__- i JIM .:_. d i DEDICATED WATER RECYCLE SYSTEM [ I '1110I WJ�- ! - DISHWASHER I C I ► it `I I I MII DRINKING FOUNTAIN _.,=r,_ ..�_ I�-.--�-I rML ---J _ 1 ,I� . , Mit FOOD DISPOSER __ .._:.� _ ._ 3 - - - FLOOR I AREA DRAIN C- __.�_ ( ( 1( C Int[ 1 INTERCEPTOR (INTERIOR) - I . INS KITCHEN SINK Reim . --- - i _ ni LAVATORY aillt U IM IL I I 1 II .fiL ■ ROOF DRAIN IT�—tI_ _M1 .I SHOWER STALL 1111MNIUMMIM � _WHIM�� SERVICE I MOP SINK � . - -. - -HI :;h; illtillilliii TOILET ,_. ' iMFaluI .I URINAL . ` I. ___ mom __..LMIIIIUIIIIEIIIIIIIIIII WASHING MACHINE CONNECTION I earn _ ? I _i_ ._. __lietwillumMaill WATER HEATER ALL TYPES MFM- - 1' � l l I1 .�_M._ am WATER PIPING I I. IIIIIIIIIIIIIIIEIIIIIIIIIIIIIII OTHER -- LI 1 -__....__ HILL _ - -____ - _. rt_._ -- L_ FIINIIIIIBIIMRIMIM p t -� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Ca NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 171 OTHER TYPE OF INDEMNITY I j BOND W '*--C) 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 Ei AGENT U SIGNATURE OF OWNER OR AGENT `-O M I hereby certify that all of the details and information I have submitted or entered regarding this application are true rate to the b st of my knowledge and that all plumbing work and installations performed under the permit ssued for this application will be in co lia 7:71yertinerr,qisioivf the : c Massachusetts Sta'.e Plumbing Code and Chapter 142 of the General Laws. .« ,�,� , PLUMBER'S NAME STEPHEN WINSLOW -I LICENSE # 12298 I SIGNATURE C ) .v` , cam- MP .7 JP[II CORPORATION L.,�'I#13281C fPARTNERSHIPSS . , .SJ LLC[ # .T, : __ _,, COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS I 8 REARDON CIRCLE CITY I SOUTH YARMOUTH STATE MA ZIP 02664 I. TEL 508-394-7778 FAX 508-394-82[36 I CELL NIA EMAIL INSPECTIONS@EFWINSLOW.COM i • The Commonwealth of Massachusetts . ii Department oflndustrialAccidents 9 • Office of Investigations Lafayette City Center 2Avenue de Lafayette,Boston,MA 02111-1750 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): 1.11 I am a employer with 90 employees(full and/ 5. ❑Retail or part-time).* 2.❑ I am a sole proprietor or partnership and have no 6. ❑Restaurant/Bar/Eating Establishment 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 no employees. [No workers' comp.insurance required]** 10.❑Manufacturing 4.ErWe are a non-profit organization,staffed by volunteers, 11.0Health Care 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 cheek 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.Lie.#1909A Expiration 21 Attach a copy of the workers'compensation policy declaration page(showing the policy numberte: 0and 1/2 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. • d do hereby cer' e the ins and penalties a n l P f perjury that the information provided above is true and correct. Signature: rL 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 30 City/Town Clerk 4.[]Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: