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Home My WebLink AboutBLDP-23-004928 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK rpt ii*f' CITY YARMOUTH MA DATE 3/8/23 PERMIT# BLDP-23-004928 JOBSITE ADDRESS 14 PATRICIA AVE OWNER'S NAME STAGG GARRETT F P OWNER ADDRESS 14 PATRICIA AVE WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESD 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 tie 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 1;2298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE IMA I ZIP 02664 TEL 5083947778 FAX CELL EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES r ' Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMITH PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1 lir" _ 3z.DP- Z 3 "C,D V AI CITY LI YARMOUTH 1 MA DATE 3/2/23 PERMIT # JOBSITE ADDRESS 14 PATRICIA AVENUE ] OWNER'S NAME, GARRETT STAGG OWNER ADDRESS SAME _ i _i1 TELI 508-280-4301 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL ._j RESIDENTIAL [ i_; PRINT CLEARLY NEW: RENOVATION: REPLACEMENT. E PLANS SUBMITTED: YES E] NO FIXTURES Z FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB =MI 111=M11111M1111 116. Imo.111.1111111111111111111.11.111111MES ' MU CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM Mal ImIL. Ilim1 [nnui • IL DEDICATED GAS/OIL/SAND SYSTEM 1 111 inn ,,, .._ . #. DEDICATED GREASE SYSTEM - DEDICATED GRAY WATER SYSTEM �. ,1 1 ' DEDICATED WATER RECYCLE SYSTEM [ _ I DISHWASHER _ DRINKING FOUNTAI i� -- 161 I,f r ..._ [ :I I FOOD DISPOSER I INN I WI I FLOOR / AREA DRAM 'i , it I in INTERCEPTOR (INT' WO' ) _ ' a H i i -. , „� _I _ KITCHEN SINK 1[ [ � I 1111111111111 LAVATORY 11111111.11111.111111111 ROOF DRAIN I = ICI ' --_-_ . I _ ?I i SHOWER STALL SERVICE ! MOP SIN L___ ..,_J l .� am I ' i TOILET 11 _ 1 ! _. URINAL _ i l;. WASHING MACHINE CONNECTION _ I I ___- .-- _� [ WATER HEATER ALL TYPES �miIlM MMil IIIM MIIIII WATER PIPING 7-11-_ OTHERIIIIIIIIIMIIIIIIINMMIIMIIIIMIIMIIIIIIII III __ INN INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES i NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY I.= 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 i, _ __ 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 proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ PLUMBER'S NAME STEPHEN WINSLOW }LICENSE # 12298 SIGNATURE �� MP i JP L_, CORPORATION ! i J# 3281C L1 1] LLC[ __]# COMPANY NAME E,F. WINSLOW PLUMBING & HEATING J ADDRESS j 8 REARDON CIRCLE € —_ CITY SOUTH YARMOUTH STATE MA ZIP 02664 - TEL r508-394-7778 __ FAX 508-394-8256 CELL N/A 1 EMAIL INSPECTIONS@EFWINSLOW.COM .,.- •. The Commonwealth of Massachusetts Department of Industrial Accidents t�= ., ,(,,,-9 Office of Investigations 4Lafayette 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 120 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]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.111 Other *My applicant that checks box#I 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:23 COMMONWEALTH AVENUE City/State/Zip: CHESTNUT HILL, MA 02467 Policy#or Self-ins. Lic. #2019A Expiration Date:01/01/2024 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 the ins and penalties of perjury that the information provided above is true and correct. — ,,,,•„/,,, 01/01/2023 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): 1.0Board of Health 2.1=1 Building Department 3.❑City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia