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Home My WebLink AboutBLDP-22-005691 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH PERMIT 0 SITE AD RESS L ROUTE 6A MA DATE 4/5/22 OWNER'S NAME ary Wood a P 22 005691 Woodward P OWNER ADDRESS 1434 ROUTE 6A YARMOUTH PORT,MA 02675 1J TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW❑ RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ NO El FIXTURFS • 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 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER 1 OTHER DESCRIPTION:sillcock INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO El 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 12298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# l 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 0 ❑ FEES$ PERMIT# PLAN REVIEW NOTES 4 ,.03 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK kT:xeir-z--. V2 2Cr�, � I ' I PERMIT #'t ; CITY YARMOUTH MA D 130122 L JOBSITE ADDRESS 434 MAIN STREET, RT 6A, YARMOUTHPOR1I OWNER'S NAMEIWOODWARD, MARY pOWNER ADDRESS SAME I TEL 860.803.4007 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL .,1 RESIDENTIAL PRINT CLEARLY NEW: ' ' RENOVATION i � : REPLACEMENT: PLANS SUBMITTED: YES El NO _ FIXTURES -1 FLOOR— BSM 1 2 3 4 j 5 6 7 8 9 10 11 12 13 14 BATHTUBM.,�„,�,„ —1---1 ,........... --F .x 1 ..Y.I 1 MIN � _ . _ . . _ - -- N UN CROSS CONNECTION DEVICE WillillillillinlINNEMISIMMUMMI am 11.11MOM DEDICATED SPECIAL WASTE SYSTEM golimparnrimmummmiumgMINITO. o 10. u,omi '. DEDICATED GASIOILISAND SYSTEM ramosiggrummia.ammoms umgagimmioni DEDICATED GREASE SYSTEM . . DEDICATED GRAY WATER SYSTEM Maillimilimsnoam mopon am[ w DEDICATED WATER RECYCLE SYSTEM Miggarniaringimi DISHWASHER ui�nK�nCrc � _ DRINKING FOUNTAIN *War � _ '11.1 _ .,1 SWIM {M FOOD DISPOSER 111111 IIIIII FLOOR / AREA DRAIN -,- - T -, _ W INTERCEPTOR (INTERIOR) .... , w: I . . 111 KITCHEN SINK _ LAVATORY .: .. ......_�:�_... ..:....... ....... ROOF DRAIN IIIIIIMMIIIIIMIIIINIIMIIINIIIIIINIIIIIIIIIIIIIMIIIIIII SHOWER STALL 111.1111011111111111.0iny IIIIIIIIIIIIIIEIIIIMINIIIMIIIIIIIMIIIIIIIIIIIIIII `' J SERVICE / MOP SINK 1 TOILET M , ..___, MI cto URINAL IMMITINIIIMININIMMINIMIMINIONIIIIIIMIIMIlmillil ---- - WASHING MACHINE CONNECTION ` un OM 11.11111111111.M.1111.101110 um .m. WATER HEATER ALL -YPES IN _[ OM v WATER PIPING r II [ [ I umo MUM _ . OTHER F�" SILCOCK ��II _ . . ,: • INSURANCE [ [ 5 COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES I , I NO 7 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v 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 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. J r •4 1/ PLUMBER'S NAME IN WINSLOW LICENSE # 12298 SIGNATURE MP JP 0 CORPORATION 0# 3281C _ JPARTNERSHIPD# LLC 0#r , COMPANY NAMECE.F. WINSLOW PLUMBING & HEATING 1 ADDRESS 18 REARDON CIRCLE - � _ i CITY i SOUTH YARMOUTH i STATE 1 MA I ZIP 02664 TEL 1508-394-7778 A FAX 1508-394-8256 1 CELL I N/A 1 EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents e Office of Investigations _ Lafayette City Center �W: f_; 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 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(inct 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 10.0 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 *My 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 for.,,o.+ eTOP 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 ee /ef the ins and penalties of perjury that the information provided above is true and correct Signature: (✓ yF /.. 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): ItJBoard of Health 2.1=1 Building Department 3D City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia