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Home My WebLink AboutBLDP-21-003759 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK q E CITY YARMOUTH MA DATE 1/7121 PERMIT# BLDP 21-003759 JOBSITE ADDRESS 7 HIGH GROVE RD OWNER'S NAME ARSENAULT JENNIFER P OWNER ADDRESS WHITNEY P&GIGANTE R 10 HOLSTEIN DR PELHAM,NH 03076-2152 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT El PLANS SUBMITTED: YES NO❑ FIXTURES 1 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 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 El OTHER TYPE OF INDEMNITY El 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 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 D ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK U =.v _ CITY=a 6LA)g 2I—�37 =U1=:�� .i��✓/Vl f� �In MA DATE �L/,_ ._,.,.w_�.��_`..�.,-_,.,._... �4� /Z� �PERMIT# JOBSITE ADDRESS ta4Q Soy 14�(atmo J I OWNER'S NAMEIo yi ta G a9±c.- I P OWNER ADDRESS I :i 0 er5 7��lc ,,,/v1k2112.6.1 TELL.0 1:?qr C��iFAXL,_. . ._-1� TYPE OR OCCUPANCY TYPE COMMERCIAL In EDUCATIONAL LI RESIDENTIAL El PRINT CLEARLY NEW:[Z] RENOVATION:1 REPLACEMENT:I`=' PLANS SUBMITTED: YES Ej NO. I FIXTURES 7 FLOOR-- BSM 1 2 3 4 5 6 7 8 9 10 12 13 14 INK NMI . I CROSS CONNECTION DEVICE _-_i� ` tl .. _., (�^;BATHTUB DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM i,l .,rr DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM 'I k_ �_ � --1,; i-- 7- DEDICATED WATER RECYCLE SYSTEM ' - Fr-11 T —11—. ', J 1, -i�i, F, DISHWASHER _ _..-_ +I. . Y. . 1L.__ DRINKING FOUNTAIN .I/ , _ l FOOD DISPOSER ' ETIIIII Tall ' FLOOR 1 AREA DRAIN RIIIIIINi `-'-' INTERCEPTOR(INTERIOR) -1 — KITCHEN SINK I--- . _ L 11-77 ,,__ - LAVATORY Pi - k (1 P,_. .il I 1 I `. SHOOWER 8TALL OF DRN I,VT _, _ � i ,11 I SINK E i' . _ 1R,F1 TOILET i t �; _.. i �� {_.,.. URINAL i 1 4 c n f , WASHING MACHINE CONNECTION ,I�_....__'i ----1 - -0---„--- VIEFIta WATER HEATER ALL TYPES � Isi WATER PIPING 11� 7:71111.— Ill . a _ M i ld E--. OTHER —- -I :-�(. P � - 'rl pi a � _..._ - I I . inn , - 1I _.. INSURANCE COVERAGE: O I have a current liability insurance policy or its substantial equivalent which meets the requirements of M V L h.142. YEtt I NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL•:; BUILDING DEPARTMENT t LIABILITY INSURANCE POLICY j, OTHERITYPE OF INDEMNITY BOND 9Y: _____ 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 E AGENT El 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.,' -= to to the h st of my knowledge and that all plumbing work and Installations performed under the 3ermit Issued for this application will be In coil,li wit 1I ertine provislo of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW I !LICENSE#112298 SIGNATURE MP( Jp® CORPORATION 3281C PARTNERSHIP 0 Its_.JLLCE#--...______ 11 N COMPANY NAME E.F.WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE t CITY SOUTH YARMOUTH STATE EM111 ZIP 02664 ; TEL 508-394-7778 FAX 1508-394-8256 I CELL I NIA 1 EMAIL 1 INSrECTIONS@EFWINSLOW.COM • The Commonwealth of Massachusetts • Department of Industrial Accidents 1•—+ I:, 9 Office of Investigations c loll,= $ Lafayette City Center ks.., — / 2 Avenue de Lafayette,Boston,MA 02111-1750 ,�.,... www mass. ov/dia �- g 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.CII am a employer with 90 employees(full and/ 5• 0 Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. rj Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 8. El Non-profit [No workers' comp.insurance required] 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers' comp.insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 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.Lie.#1909A Expiration Date:01/01/2021 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 ' i the ins and penalties of perjury that the information provided above is true and correct. Signature: Y "-- Date: 01/02/2020 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 30 City/Town Clerk 4.OLicensing Board • 50 Selectmen's Office 6.DOthei• Contact Person: Phone#: