The URL can be used to link to this page

Home My WebLink AboutBLDP-21-006636 MASSACHUSETTS UNIFORM APPL.ICATION FOR A PERMIT TO PERFORM PLUMBING WORK 4* -� CITY YARMOUTH _] MA DATE 5/17/21 PERMIT# BLDP-21-006636 JOBSITE ADDRESS 256 SOUTH SHORE DR OWNER'S NAME KIMNER KERRI LYNN P OWNER ADDRESS C/O WILLAMS HAROLD 63 VAN WIE TERR ALBANY,NY 12203 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: D RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ 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 1 1 ROOF DRAIN SHOWER STALL 1 1 SERVICE/MOP SINK TOILET 1 1 _URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent whicn 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 requ rement. 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 fcr 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 YARMOUTF STATE MA —7 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 PERMIT FEES$ PERMITS PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ".= CITY _ -,, _.__.. _ ' MA DATE L,.,JL/ ?/aLJPERMIT # NA)? - Z I - vU'(1- (. Y 3 i JOBSITE ADDRESS [2j,fl-t5tka/L-,9/ZI� ffyj' OWNER'S NAME , /t 0-2sS ..,,.. OWNER ADDRESS /IN _v I TEL1.5.A_,Va.,:iYAIFAX 1?.. TYPE OR OCCUPANCY TYPE COMMERCIAL 1 EDUCATIONAL 0 RESIDENTIAL E PRINT CLEARLY NEW: , RENOVATION: Er REPLACEMENT: . .. PLANS SUBMITTED: YES j Nolj FIXTURES 7- FLOOR—► BSM 1 2 3 4 5 6 7 8 9 10 J 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE I,_-, ___.-.1._..___. i[., DEDICATED SPECIAL WASTE SYSTEM j 1111=11141111111111111 DEDICATED GAS/OIL/SAND SYSTEM ' i DEDICATED GREASE SYSTEM I,. , _,__ __ .__ __.. .._. �....�._.-.�, ,( _, DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER i . 1i_. . i FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) ..._ ' KITCHEN SINK I:-.-_. A... - J.___ _ _.._,_ _. , .._ _,.. LAVATORY I.,. �_.r_,_ „—a ROOF DRAIN SHOWER STALL ___ - SERVICE / MOP SINK TOILET .. 1 r J . i ,._ ,. _.. URINAL l . _ _ _ - WASHING MACHINE CONNECTION t WATER HEATER ALL TYPES J , j J ..._ I I _ l ;..,..._ ._.. 1__. _. , , WATER PIPING ,; ..__. ) a ... .._. ;I 1 ri OTHER - . . ,. _. _. 1ii INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO 7 )s' (N. IF YOU CHECKED YES, PLEASE INDICATE THE TY PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW /) LIABILITY INSURANCE POLICY 171., OTHER TYPE OF INDEMNITY L 1 BOND L (36,nOWNER'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 I AGENT 11 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 ( ` 1 and that all plumbing work and installations performed under the permit issued for this application will be in corn Ii with lI ertine provisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (.\\ 11 4".• ,Arse,A. 0.—.....-- PLUMBER'S NAME [STEPHEN WINSLOW LICENSE # 12298 SIGNATURE c MP 0 JP 1:1 CORPORATION LI# 3281C PARTNERSHIPQ# .__ i LLC 0# ,u COMPANY NAMELE.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 1 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM r ; I The Commonwealth of Massachusetts Department of Industrial Accidents _; — Office of Investigations —'� Lafayette City Center y€•_� R. 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. 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 10.0 Manufacturing no employees. [No workers' comp.insurance required]** ]l ❑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•y�en��th��ns'and penalties of perjury 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): 1.1=1Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.11Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia