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HomeMy WebLinkAboutBLDP-23-002532 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 41119) CITY YARMOUTH MA DATE 1118/22 PERMIT# BLDP-23-002532 JOBSITE ADDRESS 18 ROUTE 28 OWNER'S NAME FOSTER FRANCIS X P OWNER ADDRESS PO BOX 2628 HYANNIS,MA 02601 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ NO❑ FIXTURFS FLOORS— RSM 1 2 , 3 4 5 R 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❑ 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 15298 SIGNATURE MP ElJP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX I 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 El ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .y'iffi CITY YARMOUTH MA DATE I 10/3/22 PERMIT # JOBSITE ADDRESS 22 MAIN STREET ROUTE 28 OWNER'S NAME' FRANCIS FOSTER P OWNER ADDRESS • SAME TEL 508-878-5694 FAX ,�,,.. . TYPE OR OCCUPANCY TYPE COMMERCIAL U EDUCATIONAL .W i RESIDENTIAL PRINT CLEARLY NEW: Li RENOVATION: REPLACEMENT: L PLANS SUBMITTED: YES LI NOID FIXTURES Z FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB = l MO, CROSS CONNECTION DEVICE .. .... . �_. , I, 1111111111111111-111 DEDICATED SPECIAL WASTE SYSTEM I = I € DEDICATED GAS/OIL/SAND SYSTEM i Y _ DEDICATED GREASE SYSTEM _ M DEDICATED GRAY WATER SYSTEM IMIII ! DEDICATED WATER RECYCLE SYSTEM I ' Ik r MI I 1 1111 ._._.. :. .......... • F ' DRINKING FOUNTAIN 7. 'fi MN 111111 1111111111111, MI M. RIM SIMI FOOD DISPOSER inilliffillatiallialffillitIM omit 1111.1111111W111111.11111111 FLOOR / AREA DRAIN 1M :. _. f I IMINIMI MINN INTERCEPTOR (INTERIOR) I ,E KITCHEN SINK ' .. . I . I r - I LAVATORY � . - .: . . ROOF DRAIN OIIIIIIIMIITIXINIINIIIIIIIIIIMIIIIISIIIITIIIIINISIMWIIIIIIIIIB SHOWER STALL 1k SERVICE / MOP SINK 3-7 _'3 _ rm '_ IE I TOILET '� URINAL _ ... 1 ' sa WASHING MACHINE CONNECTION 1 ( ( M _ I ' WATER HEATER ALL TYPES .1 `' WATER PIPING _ OTHER = 1 i 1 lIllaIIIIIIIIIIIINMMIMNIIIIIMIMIMINNMIMIIIIMIMM1.111111111.11111101.1.11111111MINNIMMIIIIIIMINIMIMINIMINI -111.1011111MNIMMIIIIII INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES L'ill NO , i 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. CHECK ONE ONLY: OWNER r AGENT ,r7 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 li with II ertine pro' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW m m.,.,� ..aa LICENSE # ; 1 2298 SIGNATURE MP! v JP D CORPORATION LL #I 3281 C PARTNERSHIP LJ#j LLC 7 # COMPANY NAME[E.F. WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON CIRCLE CITY iSOUTH YARMOUTH STATE MA ZIP L 02664 TEL 508-394-7778 I FAX ' 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 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.❑■ I am a employer with 99 employees (full and/ 5. ❑ Retail or part-time).* 6. U Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. Office and/or Sales(i . employees working for me in any capacity. ❑ n^1 real estate, auto,etc.) [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.❑ 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 ' 7 the g�hins and penalties of perjury that the information provided above is true and correct. Signature: /�' ---�1�- 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.❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia