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HomeMy WebLinkAboutBLDP&G-21-007274 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Q: l(a CITY YARMOUTH MA DATE 6/15/21 PERMIT# BLDP-21-007274 JOBSITE ADDRESS 2 ALISON LN OWNER'S NAME Elaine Dickinson P OWNER ADDRESS SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ 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 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 El NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY El BOND El 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 1Q298 SIGNATURE MP El JP El 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 PERMIT FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK is s CITY yarmouth .. ..0 —I MA DATE I 06/10/2021 .._."...__._a_.,... ' PERMIT # AnL , JOBSITE ADDRESS 2 alison lane, westryarmouthK OWNER'S NAME dicklnson, Blaine r OWNER ADDRESS 518369.3821 TEL , FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: I RENOVATION: REPLACEMENT: LI PLANS SUBMITTED: YES 0 NOID FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 j 6 7 8 9 10 11 12 13 14 BATHTUB . l _IL L.__JL ..._. _ . CROSS CONNECTION DEVICE . ... . - _ ._. f . i DEDICATED SPECIAL WASTE SYSTEM L, w ._-- _ _ _. „ � T m. _ " . -F am INN DEDICATED GAS/OIL/SAND SYSTEM r-- r 0111111111111111111. DEDICATED GREASE SYSTEM ... ice __ , . am1 �I DEDICATED GRAY WATER SYSTEM _ II111 : I IIIIIMIIIIII111111111111111111 DEDICATED WATER RECYCLE SYSTEM (--- DISHWASHER .. li .. ';._ _.._ .V .•- i �.............. DRINKING FOUNTAIN I FOOD DISPOSER 1111111R111411111111111.111MINIIIIIMININIIIIMINIIIIIIIIIIiiii FLOOR / AREA DRAIN ' � I! 1 INTERCEPTOR (INTERIOR) * __.- — f`._ `r ' 1' 'I �' T. KITCHEN SINK IIIIIMIIIIIMIMIIIIIIIIIIIMIIIIIIIIummomml MIIIOIIIIMFIIFMMIIIIIMMIIMIMMIIMIIIMILMIIMMIIIIMIIIMIIMIIIIIIIMIIIII _ _ ROOF DRAIN MM.UMW ` .. lr I I i II SHOWER STALL MIME ICI an 1111111111111M1111 SERVICE / MOP SINK FM NM IIIIIUIIMIIIIMIIIL TOILET Y, 1 MINHIMMININIMMIEMEMIMINIMINUMMEMINI URINAL l _. ,ti ... _. _ ,_ . _ WASHING MACHINE CONNECTION ,i . .�;:11 I _ CT i. . .;-�: WATER HEATER ALL TYPES a _ WATER PIPING , - .. 1 -ir —I Mill MN — OTHER 1I - .. !NIIIIIIIIIIIIMIIIII MUM T .. li I ... , , _ IINN _ .I w/o 553717 $40 00 q12 ` INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES pi NO h IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LABILITY INSUJPoNCE Pni !rV ' v QTH[P TVDF OF I'IDE!,,4 IITV 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 to 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 com lia with II ertine pro' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r ,• ..d.0 � PLUMBER'S NAME STEPHEN WINSLOW LICENSE # 112298 J SIGNATURE MP i v JP 0 CORPORATION 1 , # 3281 C PARTNERSHIP` # — LLC El# COMPANY NAME; E.F. WINSLOW PLUMBING & HEATING —I ADDRESS [iEARDON CIRCLE -- CITY_ SOUTH YARMOUTH STATE FMA i ZIP 02664 TEL : 508 394-7778 FAX [508-394-8256 3 CELL N/A ' EMAIL ' INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents ��'� Office of Investigations Lafayette City Center l``/ 2 Avenue de Lafayette, Boston, MA 02111-1750 M. - 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 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. ❑ 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 ot,.cers 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.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.11I 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#I. 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, 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: 1' �` .A.4.0./'�-.. Date: 01/02/2021 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): 1.111Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.El Licensing Board 5.❑Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 15,2021 PERMIT# BLDP-21-007274 V r-t JOBSITE ADDRESS LALISON LN OWNER'S NAME Elaine Dickinson G OWNER ADDRESS SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 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 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 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER 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-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP Q MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# _LLC El# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsna 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 1 Piiri,.t.k:,___,.. ,,i,:, 1=►,. CITY ' yarmouth MA DATE 06110/2021 PERMIT # .y JOBSITE ADDRESS 2 alison lane, west yarmouth OWNER'S NAME dickinson, elaine GOWNER ADDRESS TEL 518 369 3821 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY 1 NEW: RENOVATION: REPLACEMENT: v : PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 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 w UNVENTED ROOM HEATER WATER HEATER OTHER ..,.. __ .._ .__ 1 , wlo 553717 $40.00 ql2 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES � , NO ij i I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY r , g OTHER TYPE INDEMNITY BOND y-I 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 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 1 a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. O. y --• /./(//...........;4- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP v MGF JP , JGF ... LPG! . CORPORATION - # 3281C PARTNERSHIP # LLC # .n COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ' ADDRESS I 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 ,T EL �508- 394-7778 FAX 508 394 8256 CELL FA -- .EMAIL INSPECTIONS@EFWINSLOW.COM r. The Commonwealth of Massachusetts • Department of Industrial Accidents t —+ Office of Investigations = Lafayette City Center %' 2Avenue de Lafayette, Boston, MA 02111-1750 ' f� 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 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. ❑ 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.❑ 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.] 12.0 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: 01/01/2022 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, 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. ("'� 01/02/2021 Signature: �` Y "` --. ---" 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 50 Selectmen's Office 6.El Other Contact Person: Phone#: www.mass.gov/dia