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HomeMy WebLinkAboutBLDP&G-22-004019 #6 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 1/20/22 PERMIT# BLDP-22-004019 JOBSITE ADDRESS WILLOW ST OWNER'S NAME Christopher Fucile P OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES l FLOORS—. RPM 1 2 3 4 S 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 0 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 1E298 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 EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ? $ y l CITY YARMOUTH WEST __.�._ MA DATE i 1/12/22 _ PERMIT # 'Z L. - 1_1 6, i (-7 JOBSITE ADDRESS 6 SIMPSON AVENUE I OWNER'S NAME CHRISTOPHER FUCILE OWNER ADDRESS SAME TEL 401-465-0357 FAX - .......:.1- TYPE OR OCCUPANCY TYPE COMMERCIAL r EDUCATIONAL RESIDENTIAL ril PRINT CLEARLY NEW: r , RENOVATION: i L_...,. REPLACEMENT: Li PLANS SUBMITTED: YES El NO FIXTURES Z FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 yy 14 BATHTUB 1 -_ 88 ` . _ CROSS CONNECTION DEVICE p DEDICATED SPECIA_ WASTE SYSTEM i--...- li_it-7 _.. ._�..i I .. _ DEDICATED GASIOILISAND SYSTEM [ -7 1 .-, -l ur _ ;r_-7.-t1I!'1, ' ..--1i_ i____.......l,,iw i _ : DEDICATED GREASE SYSTEM _ „--,-_ -- DEDICATED GRAY WATER SYSTEM .._..._.,.�.: 11 — _ w_._. C . t DEDICATED WATER RECYCLE SYSTEM ii l m „r DISHWASHER L DRINKING FOUNTAIN _.. „mil.. .11 ___ _.. ..: :_ µ _ _." ,.._.. .: . _ I ::::"., l _ 1 FOOD DISPOSER ' , FLOOR ( AREA DRAIfJ I — _ MI^ u :._ INTERCEPTOR (INTERIOR) II _ ° II '_ � _,ate KITCHEN SINK _ ..-.:...._ _..._. ..iE1IJ__� ._. _.i f '_ ,i v.,_.._ .:.... _ . LAVATORYI 1 11 E inn' ____„,. ..., ROOF DRAIN ._ I `� 1 t f I ,_ I SHOWER STALL E. .. I . �.:_I . � SERVICE l MOP SINK � " ( I r "-�� s� _. .-. _.,,.,._ �g �. li .E _u . ,, l. . 71 I TOILET t --- - , I qq' E E URINAL . ' . . 7,,,_ 1 WASHING MACHINE CONNECTION _ � �- i WATER HEATER ALL TYPES 1 I I= _ L; I� � WATER PIPING _... , : __...._ ... f OTHER I g ' � I' � I- y a i 1 C Il g t s INSURANCE COVERAGE: i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [, NO L IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1 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 corn lia with II ertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME [STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP JP j CORPORATION IL,, # 3281 C PARTNERSHIP I , 1#'L LLC M 5#; COMPANY NAME E.F. WINSLOW' PLUMBING & HEATING ADDRESS s 8 REARDON CIRCLE 1CITY 1 SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 1 CELL ' N/A EMAIL INSPECTIONS@EFWINSLOW.COM , The Commonwealth of Massachusetts Department of Industrial Accidents i ;, `� Office of Investigations (7 Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 M S=� 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): I.❑■ 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. ❑Nor-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.ElWe 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 ghins nd penalties of perjury that the information provided above is true and correct. Y --A.A.— Signature: Date: 12/01/2021 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): 1.0Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Vie CITY YARMOUTH MA DATE January20,2022 PERMIT# BLDP-22-004019 JOBSITE ADDRESS WILLOW ST OWNERS NAME Christopher Fucile G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES NO El 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 0 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 inspectionsla�.efwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i_ - 7 _:sm, _ �-i 6 j r - , CITY YARMOUTH (WEST) MA DATE 1/12/22 PERMIT # -yl JOBSITE ADDRESS 6 SIMPSON AVENUE OWNER'S NAME CHRIS-TOPHER FUCILE OWNER ADDRESS SAME TEL 401-465-0357 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E `' RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: ✓ PLANS SUBMITTED: YES NO APPLIANCES Z 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 ' 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 r AGENT ` 1 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:a;p 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 MGF j JP JGF LPG' CORPORATION i # 3281C PARTNERSHIP # :_: LLC # COMPANY NAME: E .F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 ....j ... FAX 508-394-8256 CELL N/A EMAILI INSPECT ONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents I ix __ ,.ti Office of Investigations t Lafayette City Center iy 2 Avenue de Lafayette, Boston,MA 02111-1750 ,,,`/ k 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 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. El 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.ElWe are a non-profit organization, staffed by volunteers, 11.0 Health Care 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:01/01/2023 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 ptiins and penalties of perjury that the information provided above is true and correct. Signature: Y "` �^-�" Date: 12/01/2021 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): I.❑Board of Health 2.0 Building Department 3.1=1 City/Town Clerk 4.El Licensing Board 5.❑Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia