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Home My WebLink AboutBLDP-21-007075 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK /= CITY YARMOUTH MA DATE 6/7/21 PERMIT# BLDP-21-007075 I.I_.. JOBSITE ADDRESS 132 GREAT WESTERN RD OWNER'S NAME KNAPSACK WILLIAM J ' P OWNER ADDRESS KNAPSACK MOLLY L 68 LAMPLIGHT DR KENSINGTON,CT 06037-1806 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 1 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❑ 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 at 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 112298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# j LLC ❑# ] COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com ROI[:H PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES \es \o THIS APPLICATION SERVE AS THE PERMIT ❑ FEES S PERMIT# PLAN REVIEW NOTES V. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -, — r CITY . .-��Yi+(eM nr,,rt- Is.....�,--.....r.------ .rr.�...-_„-."_.,. MA DATE PERMIT# b �Vr, JOBSITE ADDRESS 1 11E-Q=% ...(Aiii "k/i i,14 .44 OWNER'S NAME _Poo •nia �tC l� ......,_ ,�_T,.! P „, OWNER ADDRESS G L 1,r� t ..t �._. . I TEL `'.� ,`6, ?_� . i!� ?„�_� LI FAX - TYPE OR OCCUPANCY TYPE COMMERCIAL , EDUCATIONAL 0, RESIDENTIAL PRINT CLEARLY NEW: [J RENOVATION: F.1 REPLACEMENT: ill PLANS SUBMITTED: YES D NOD FIXTURES 1. FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _. . [.* 'I -- -_1 ,--- ., . _= -.I -=_ - ARM . _ _ 1 -- ] w.rr ss reaw - w+-�:: . CROSS CONNECTION DEVICE _:._ ._.. --__ = -__ -_--. � -'-- _ - i - - C 1, 1 _._ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILSAND SYSTEM _ _ _ _. g _j _ _��. ,.____ um,i_t _ DEDICATED GREASE SYSTEM 1'- -'' : 011 1_ � I ( _�__ ___... �1 DEDICATED GRAY WATER SYSTEM _. allt . _� „___!1„,„! Li____'' __, i__„tMM__I__P__7:_____1' DEDICATED WATER RECYCLE SYSTEM (___ ____ _ -L_ ,T� _ -___! _ ' ; _ DISHWASHER , , TT- —�]LJL' --- i. � --�-__ IIT DRINKING FOUNTAIN . _. '' T j( --'-- .r.v--..- �. z_- _'—" - y---'- ate.-:".:-. '�,�-� a�.�•.,:�.1 .'..x�:a -..- FOOD DISPOSER 1 __.�.._-' - J_ _�',i �, - 1L I .,_____I ,„.�.J,. . r i FLOOR/AREA DRAIN ;� s_ ��1 ,._1,.T I �__ ___:1 -_, LT__1 r_ _ .1 INTERCEPTOR(INTERIOR) (.. ;�� L-;i,, L.,�;..�_;/ ._=�-.I L Ly-. . :..L J _Ili •--- ._ L. KITCHEN SINK �— i�J i _____: _` r LAVATORY 1 _.I I ' A .:/.-_•�r•-_-•fli-� - �. ._-..-._�L.='S'�--� �. � -77=t�I:�— _ � 7�•��-' -Awil1 �.i ROOF DRAIN - :-. - JL -- - • - ..- ---- SHOWER STALL L = . _.. = _ SERVICE / MOP SINK . - _ HhzT' - - -' L- _- I_ _J .""-: _ L TOILET L.�. _ 1-__ -_i . --__A___1 ...__ _:L JL—.«. URINAL — Y--'[,-_-' ILIMME-111111111.111.10.1111-01M- -t ' - -_.I _I --_--I ---WASHING MACHINE CONNECTION __ .._' __ i , WATER HEATER ALL TYPES a111L �'� . _ _.�_. 3�__.._ . M �__� 11 WATER PIPING . ."-__-__'; 1111111 -_,._.. 1 ._-;� --- — 1 �. - - --- 1 - - OTHER L.,,,,,,,....„, - - L- =1 -_-----' °I - _ -- — _______ . _ ' I_ . '. I [.. _ I____� INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Ell NO L IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY „ ] OTHER TYPE OF INDEMNITY i i BOND i„.j 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 n 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 co Ii. : with II ertine praYision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. j PLUMBER'S NAME ' STEPHEN WINSLOW -"LICENSE # 12298 SIGNATURE MPT,%il JP . ,i CORPORATION . . # 3281 C PARTNERSHIP , 4 JLLCI . _ ( , +v COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS L8 REARDON CIRCLE _1 CITY SOUTH YARMOUTH � 1 STATE L MA �1 ZIP [02664 _� TEL 508-394-7778 FAX 1508-394-82561 CELL LN/A 1 EMAIL INSPECTIONS@EFWINSLOW.COM • 1 .• The Commonwealth.of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center Ntzt �oW 2 Avenue de Lafayette,Boston,MA 02111-1750 Nos 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 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. [1] 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]** 4.❑ We are a non-profit organization,staffed by volunteers, 11.❑Health Care with no employees. [No workers' comp.insurance req.] 12.❑ 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,ent, as well as civi 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/J,ins and penalties of perjury that the information provided above is true and correct. Si nature: 7 y ��`....f/.�.. 01/02/2021 g 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): 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.[]Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia