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Home My WebLink AboutBLDP-23-004937 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 3/8/23 PERMIT# BLDP-23-004937 JOBSITE ADDRESS 11 JOHNSON LN OWNERS NAME KATHLEEN DOWNING OWNER ADDRESS 11 JOHNSON LN WEST YARMOUTH 02673-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:0 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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 1R298 SIGNATURE MP 0 JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 TEL 5083947778 FAX I 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 ID ❑ FEES$ PERMIT# PLAN REVIEW NOTES -" IVIASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =:l. , ;� (�Ll Gee MA DATE 4/23' PERMIT#/ -if"" Z3 �/!37 CITY ��,�_ �__.� �._._..�� _» JOBSITE ADDRESS •l/ „ pil _ iU ',._....________I OWNER'S NAME /4/9-171-4_4e0,,POW/C,-.?.//,t'fr........,_.1 OWNER ADDRESS ._. `5/ __- 1 TEL : 5.:-.2 Ye>LAM CFAX. �r^ r TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL 0 RESIDENTIAL Er- PRINT CLEARLY NEW: El RENOVATION: ffli REPLACEMENT: 0 PLANS SUBMITTED: YES 0 NO gt FIXTURES ].- FLOOR-} BSM 1 2 3 4 j 5 6 7 8 9 10 11 12 13 14 BATHTUB { -.__. •_ _. - t - �ti __.. _ ._ . ' • CROSS CONNECTION DEVICE { - _____...° . ,_.-.-___• -_.. : J 1_ ::-1_ . , i I DEDICATED SPECIAL WASTE SYSTEM t__,.__, ____.__...4__.____,_______ �.___.__' �.___n'�,-_�.__.jf.__�-r��_._.r __ ' DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM ` 1 1 '1 DEDICATED GRAY WATER SYSTEM I _ . , _ _.._ _..__.__: .___ _ ____.__._. __.• _ DEDICATED WATER RECYCLE SYSTEM .•_____ _,_____: _....._ _._.-_.•_._' __._ _ ____ . _._.._ __m__.__ 'I I DISHWASHER ,...__. I»�,....__ I_._-,.___ __.-.•..._J•...r,.....,,_1_...._ J._._,,,..,•- DRINKING FOUNT - __----1-----'.I-- ----.» ---- -____. ` ...-__' --- I----•----1 ---_ _ ___ i FOOD DISPOSER """17a , - __ _ _..-. . -- -_..- --• _ _ - - - _ _ _ FLOOR 1 AREA D' 'I n' r7 g __...i .•. _ _..__. INTERCEPTOR (IN. Pr' 9R) CZ o: ; __..-.__._ ..Y._._ L______J -....._.�____._._,_: __..m__,-{___.__r_ 1{_.._.. „ ____,_ __..___ ___" __='r •.f__.-- --- .- �KITCHEN SINK , n I-_--•_ ,____ !____•.! --- _-'j---- -.i_.�__ J.__.__ 'L_.._.._j._..-.___';—_-._--.I, - -----, LAVATORY W . Q tli II _... I_._.__._..__. -2 _-,r._: �_-_ _ . ROOF DRAIN ____:___:;_______' SHOWER STALL Ili z �_._._.. ` - cll -----1--- . I• .._. _. _ _._. I ,(- 4-.. -�{.__...- - - __�. SERVICE/ MOP S.I TOILET •" m m I-- l .._�.I 1�.. _• _. - _ ..�_._» 1._.___. ; .�._.. URINAL - - --- .. r - i._._ ._ i H. - - I----,- -- -- f._ j - -- -• -- - - - WASHING MACHINE CONNECTION ' - - -_ _ ., _ _-.___ __ T WATER HEATER ALL TYPES .. _ _ - 1_____, - WATER PIPING _ --------- - -- -.. ._ ___-_ . - Q._ OTHER 111111,1 TLI.i _- � HLtT: TI - _ INSURANCE COVERAGE: • I have a current liability insurance policy or its.substantial equivalent which meets the requirements of MGL Ch. 142. YES O. _NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E OTHER TYPE OF INDEMNITY D BOND Q 4 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the .0Z Massachusetts General Laws, and that my signature on this permit application waives this requirement. --...., _ CHECK ONE ONLY: OWNER ri AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are truer to 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 corn Zia 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 MP0 JP0 CORPORATION[# 3281C PARTNERSHIP# � �_f LLC A COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Contmonwealt/1 of Massachusetts h Department ofIndustrial Accidents z ,J t_w Office ofInvestigallons Lafayette City Center • • 2 Avenue de Lafayette,Boston,Mei 02111-1750 www.rnass.gov/dla 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 99 employees(full and/ 5, ❑Retail or part-time).* 6, ❑RestaurantiBat/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. C Office and/or Sales(incl, real estate,auto,etc.) employees working Forme 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 e, 152, §1(4),and we have 10,0 Manufacturing no employees, [No workers' comp, Insurance required]** j 4,❑ We are a non-profit organization,staffed by volunteers, 11,❑Health Care with no employees. [No workers' comp. insurance req,] 12,0 Other *Any applicant that checks box/lI 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'cotnpensution policy Is required and such an organization should check box Nl, I curt an employer Mat ds 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: 01101/20z 1f 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 r e.the' Ins and penalties of pedal that the information provided above is true and correct, Signature: Date: 12/01/204. Phone 1/: 508-394-7778 Official use only. Do not write in.this area,to he completer/by city or(own official. City or Town: Permit/License# Issuing Authority(cheek one): 1 fBoard of Health 2.D Building Department 3E City/Town Clerk 4,❑Licensing Board 51]Selectmen's Office 6.❑Other Contact Person: Phone www.tnnss.gov/dia