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Home My WebLink AboutBLDP-22-004133 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK rye!? CITY YARMOUTH MA DATE 1/25/22 PERMIT# BLDP-22-004133 <<I� JOBSITE ADDRESS 2 WHITES PATH OWNER'S NAME TWO AND TWELVE WHITES PATH P OWNER ADDRESS L B2 WHITES PATH SOUTH YARMOUTH,MA 02664 LLL TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ 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 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 IN)EMNITY❑ BOND El OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have tfe 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 El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA —I ZIP 026641207 TEL FAX I CELL EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES S PERMITS PLAN REVIEW NOTES t3 c D '- 't. Z -c o-f / 3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - Taw CITY YARMOUTH SOUTH) MA DATE h2/1O/21 ,rw PERMIT# Itip t ?.-w 2 • JOBSITE ADDRESS 112,WHITES PATH UNIT 5 I OWNER'S NAME SUBWAY SANDWICHES aytAvvic OWNER ADDRESS 'SAME 1 TEL(508-394-9500 IFAX[ TYPE OR OCCUPANCY TYPE COMMERCIAL LV EDUCATIONAL El RESIDENTIAL l PRINT CLEARLY NEW: ,,,, RENOVATION: REPLACEMENT: LI PLANS SUBMITTED: YES `L I NOLJ FIXTURES Z FLOOR-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB l r CROSS CONNECTION 111.1111.MONO Mill 1111011 DEDICATED SPECIAL WASTE SYSTEM 1.11.11111111. NMI 1111.1111111111M MB MK DEDICATED GAS/OIL/SAND SYSTEM 1 ...... . DEDICATED GREASE SYSTEM 11110111111111Mil MI SIM MISIME ME ali DEDICATED GRAY WATER SYSTEM EadilliMMIM wig MM. miff um mg NM .. _ LIM DEDICATED WATER RECYCLE SYSTEM 1.111Malailli .1111111 MP UiJnVvrrSnEn DRINKING FOUNTAIN FOOD DISPOSER MI FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) MEC { ............... . KITCHEN SINK 1411.1 LAVATORY . . .. . .. .. 11111.1.111111.1111111111m1111WIM mu Mil ROOF DRAIN .. .SHOWER STALL NOMMININNIMMORMIIIIIIIIMMIIIIIM SERVICE / MOP SINK 1 TOILET .11.11111111111111MIUMMINIMMUSIVIIMM11.111111111111 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING nii1111111111111111 - OTHER MITION11111111 __M....1111111111111111111111111111 ..... MN 1111111111111111111111111111M liMmes INSURANCE COVERAGE: I have a current liabililyinsurance 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 INSL RANCE POLICY OTHER TYPE OF INDEMNITY s 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 cf 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 # L12298 SIGNATURE MPFJ JP j CORPORATION r # 3281C 1PARTNERSHIP # COMPANY NAMEE.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY IOUTH YARMOUTH -wy....- STATE MA ZIP [02664 TEL 1.p8-394-7778 FAX 1508-394-8256 ' CELL NIA EMAIL INSPECTIONS a@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 9:5 t'4 Office of Investigations Lafayette City Center r„,/,g 2 Avenue 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): 1.0 I am a employer with 99 employees (full and/ 5. ❑ Retail or part-time).* 6. (l Restaurant/Bar/Eating Establishment 2.Li 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. 0 Entertainment their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health 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 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 ' the ins and penalties of perjury that the information provided above is true and correct. Signature: �. A - 12/01/2021 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.DBoard 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