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Home My WebLink AboutBLDP-23-003285 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK g y-_r. CITY YARMOUTH MA DATE 12/13/22 PERMIT# BLDP-23-003285 118 JOBSITE ADDRESS 24 NICHOLAS DR OWNERS NAME PESSA MICHAEL A P OWNER ADDRESS PESSA LYNN A 24 NICHOLAS DR YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ FIXTURES FLOORS BSM 1 2 3 4 , 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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 N2298 SIGNATURE MP ❑ JP ❑ 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 CELL EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ 0 FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ITS,-1� Y, - F' CITY YARMOUTH MA DATE 12/8/22 7 PERMIT # 5 . JOBSITE ADDRESS I 24 NICHOLAS DRIVE 1 OWNER'S NAME LYNN PESSA l P OWNER ADDRESS SAME STEL 774 994�. _,.��.. .._ _ w.......w...m 1340 FAX=I [ AME , TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL El RESIDENTIAL 71 PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES i,..,3 NO(, FIXTURES Z FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ CROSS CONNECTION DEVICE ;: DEDICATED SPECIAL WASTE SYSTEM _ I 1, _ :. ' ,, ' f DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _ I I L �.. I.,^ . DEDICATED GRAY WATER SYSTEM 44 i k. DEDICATED WATER RECYCLE SYSTEM I I. I 'In IIIIIIMIMMIll DISHWASHER 11 -ifr 1.. i I, r. DRINKING FOUNTAIN I 1 mi OM i i r ••' D' INTERCEPTOR IIIIIIIIIIIIIIEIIIIIIIIIIIIIMIIIIIIIIIIIWIIIINI INNIIIIIIIIIIIFNIIIIIIMllitall LAVATORYbEL I ROOF DRAIN , HJHJHiE:.d . EHE-SHOWER STALL III 1--- '11111111111.1M !MIA 111111MI=Hill l' IMMO niiiiiiiii- iiiiiMinli IIIMIII 11111 -11111111 . n aii MI IIIIIIMIIIIIIMIIIIII URINAL MM. iiii Erni- ' 'MI Erni WASHING MACHINE CONNECTION 'I '' 1 I noin , WATER HEATER ALL TYPES 1 1 . i 7l..,... : a WATER 111111MMTIMMIllilM, OTHER 1 aill1111111311 ; I iminmr- ammumaiiiiiiiiiimil laiimiiiiiiiiiiiiimi l _3 I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES r i j NO (,_ ; IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNIT Y I & BON VD 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 co lia with II ertine pro'isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME [STEPHEN WINSLOW ]LICENSE # 12298 SIGNATURE MP i JP El CORPORATION fir # 3281C PARTNERSHIP,# LLC # COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH , STATE MA J ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS aOEFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 9 ,`'-, r9 Office of Investigations (? _. 141 Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 le% wwwmass.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. CJ 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.ElWe are a non-profit organization, staffed by volunteers, 1 I.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.111 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 • e thin a d penalties of perjury that the information provided above is true and correct. Signature: ^\ 7' 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 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia