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Home My WebLink AboutBLDP-23-003922 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 1/18/23 PERMIT# BLDP-23-003922 nt JOBSITE ADDRESS 61 WOLFSON RD OWNER'S NAME John Doucet P OWNER ADDRESS 61 WOLFSON RD SOUTH YARMOUTH,MA 02664-1345 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 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❑ 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. PLUMBERS NAME Stephen Winslow LICENSE#R298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 18 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 ❑ ❑ FEES$ PERMITH PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK y. " = CITY Yarmouth 1 MA DATE 1/12123 PERMIT # -3 - 3 5' 2 2- JOBSITE ADDRESS 161 Wolfson Road 1 OWNER'S NAME John Doucet . 1 P 1-- OWNER ADDRESS same TEL1,781-392-8396 FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL F .j EDUCATIONAL 1__m_j RESIDENTIAL 0 PRINT CLEARLY NEW: [.,1 RENOVATION: '. i.__\ REPLACEMENT: Ej PLANS SUBMITTED: YES L. NO, ,1 FIXTURES -1 FLOOR BSM 1 1E1 3 4 5 6 7 8 9 10 11 13 14 BATHTUB ; 1 I --_---Ii CROSS CONNECTION DEVICE m1 DEDICATED SPECIAL WASTE SYSTEMv. J�� I � IIN _ .,. . ._ INS 1 I 11111111 DEDICATED GAS/OIL/SAND SYSTEM I _ I 'I I DEDICATED GREASE SYSTEM Mall. MIN INN _ ,II111111111111';1`NM DEDICATED GRAY WATER SYSTEM IIIIMMIniii MNIMI IN.IINN L J111111111111111111I111111110111111101111111110111M111111 DEDICATED WATER RECYCLE SYSTEM ( :f r __ ' . I DISHWASHER , _ -.- '- DRINKING FOUNTAIN MN FOOD DISPOSER I FLOOR /AREA DRAIN 7_____ amin' MR•1111111.1111111111111 INTERCEPTOR (INTERIOR) IIIIIMIIIIMIIIIIIIHIIIIIIMIIIIIINIIIIM 111011111111111 . KITCHEN SINK 11111.1MILM1111.11111nMalla IIIINIMIIIMIIIMINMMIMIIIIIIIIIIIIItnllIl LAVATORY 1111111.111111111111101-11.111.6111111.0,110111111111110111111111111M111111Mmaileilii ROOF DRAIN SHOWER STALL 1111111111.1111110MIIMIIIMIIIIIIWIIIIIIIIIIIIIlhI SERVICE / MOP SINK 11111.111111111111111111111111111111111_._ TOILET ... ,i _ , am r• URINAL _. z_ . '.. �11111111 I WASHING MACHINE CONNECTION _ ._. J . __-- WATER HEATER ALL TYPES ; __ .1 IIIIIIIIIIIII WATER PIPING �_. ._ ' OTHER : . j-- all WM 1 MN MIS E ,NMI 'MEE= ... 1 .... NM 1111111 IIINIHIIIIIIIII NM INNIS MI MINIM -- 11111111111111111111. . i 11 allierinili INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 71 NO El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY r OTHER TYPE OF INDEMNITY l 1 BOND 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 L_ 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 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 corn lia with II ertine pro)cisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r4,, .0.4040 ,+,._.gyp PLUMBER'S NAME STEPHEN WINSLOW ? LICENSE # 112298 SIGNATURE MP ''.-.# JP j CORPORATION El#[3281_C _ IPARTNERSHIPLJ#1 — . LLC El#F.._ -7] COMPANY NAME I E.F. WINSLOW PLUMBING & HEATING _ ADDRESS 8 REAR-DON CIRCLE :d rm CITY SOUTH YARMOUTH STATE MA ZIP [02664 _ TEL 508-394-7778 _ ...i FAX 508-394-8256 CELL NIA EMAIL INSPECTIONS@EFWINSLOW COM ., _._-_ v,, The Commonwealth of Massachusetts 4 s Department of Industrial Accidents 9ti 9, Office of Investigations (L. Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 '/ ww».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 99 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, 11.0 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: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 the ins and penalties of perjury that the information provided above is true and correct. , / Signature: ? "' ^�../.-" 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): 1.1=1Board of Health 2.0 Building Department 3.1=1 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia