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HomeMy WebLinkAboutBLDP&G-23-004627 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 2/21/23 PERMIT# BLDP-23-004627 .1' JOBSITE ADDRESS 10 OAK GLEN VILLAGE OWNER'S NAME FINKELSTEIN RUTH ya s• P OWNER ADDRESS 10 OAK GLEN VILLAGE YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ 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 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 D 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 i work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massa— bing Code and Chapter 142 of the General Laws. ")hen Winslow LICENSE 142298 SIGNATURE CORPORATION ❑ PARTNERSHIP CI# LLC ❑# I A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR STATE MA ZIP 02664 TEL 5083947778 EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Ses No THIS APPLICATION SERVE AS THE ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =Ritt—_ , , '" _ CITY Yarmouth I MA DATE 2/15/23 PERMIT # 2 ", (Lie "- � JOBSITE ADDRESS 110 Oak Glen OWNER'S NAME Ruth Finkelstein .....1 P i OWNER ADDRESS ,same TEL 508 362 0150 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL 1-.711 CLEARLY NEW: L.._1 RENOVATION . 1 REPLACEMENT: PLANS SUBMITTED: YES NOIJ FIXTURES Z FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB._ CROSS CONNECTION DEVICE k v `, DEDICATED SPECIAL WASTE SYSTEM j DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM 1 Mall liMM"-Ilill111111111111•111111:111111111:1111111MIM NOM NM DEDICATED GRAY WATER SYSTEM _I' 1 im-17-11 1111.1 ' ginumg . DEDICATED WATER RECYCLE SYSTEM ` ..._ _ _ . ' ,. '. . .. F I DISHWASHER .. __ . . DRINKING FOUNTAIN _ , ....M !WI _ 1' , FOOD DISPOSER1111111 !MI . _ FLOOR / AREA DRAIN - 7, :5 vv isi j i INTERCEPTOR (INTERIOR) IrTHI- l � KITCHEN SINK ,t F . k LAVATORY € _— ,,— , _ _� , , I ROOF DRAIN I, , Ellill i SHOWER STALL ._ SERVICE / MOP SINK .111111.111111111111111.1=1.1111111.11111111111111[Millill 'NMI MI _ TOILET 1101111111111.1111M '[ URINALiri!1 WASHING MACHINE CONNECTION L __ ammo r WATER HEATER ALL TYPES i .. _ , _ WATER PIPING �.. ' si NM la:. _ _ ' _ __ I OTHER _ _. . . [ _innani1111111 1 111111 a 1-11,-. i INSURANCE COVERAGE: :. ........ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO F_, IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITYL. BOND _... } OWNER'S INSURANCE WAIVER: I am aware that the iicensee 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 [— AGENTµ. ,„:. 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 corn lia with II ertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW 1 LICENSE # i 12298 SIGNATURE MP JP ,__ CORPORATION A# 3281C PARTNERSHIP[ ... # LLCJ# COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH J STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts f� Department of Industrial Accidents f9� l;f ;n! -----+:y Office of Investigations c` Lafayette City Center 4,7 /SW ' 2 Avenue de Lafayette, Boston, MA 02111-1750 '',, „ l 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 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0Health 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 ' e the ins and penalties of perjury that the information provided above is true and correct. • Signature: 7' '/'� 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❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.0 Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTHVt MA DATE February 21,2023 PERMIT# BLDP-23-004627 JOBSITE ADDRESS 10 OAK GLEN VILLAGE 1 OWNER'S NAME FINKELSTEIN RUTH G OWNER ADDRESS 10 OAK GLEN VILLAGE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO El FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER • DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS • _ MAKEUP AIR UNIT • _ OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT • TEST UNIT HEATER • UNVENTED ROOM HEATER WATER HEATER 1 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 El OTHER OF INDEMNITY❑ BOND El 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-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP El MGF © JP El JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP El# 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 inspectionsta7.efwinslow.com S31ON M31A3H NVld #iIW2iad $ 33d ❑ ❑ 11W213d 3H1 SV S3AiES NOI1VOIlddV SIHl ON SaA S310N NO1103dSNI 1VNld AINO 3Sf1210103dSNI 210d 30Vd SIH1 S31ON NO1103dSNI SVO HOl02i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'Yarmouth I MA DATE 2/15/23 PERMIT # L r Li le 2- JOBSITE ADDRESS 10 Oak Glen OWNER'S NAME Ruth Finkelstein GOWNER ADDRESS same TEL FAX :. ....:.,....:.w..a.«:......:.:...:.............w....w.,w,..r:o vas .. ... ......r., .....,: i.... ... ........ ,...,.. ........ ..3t{$:4SriS6di �' f OR TPRINT OCCUPANCY TYPE COMMERCIAL 1 EDUCATIONAL RESIDENTIAL CLEARLY NEW. 1-1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS-0 BSM J 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ..._�...._.. BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR — �---____ -- -- ---------------- �_. _� GRILLE INFRARED HEATER LABORATORY COCKSMll- MAKEUP AIR UNIT OVEN _ _-.w ......�... - POOL HEATER , ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY - OTHER TYPE 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 and accurat to the b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP , MGF JP JGF ` LPGI CORPORATION # 13281C PARTNERSHIP 0# LLC , # COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 JTEL9 -7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM SL,>.„ The Commonwealth of Massachusetts • Department of Industrial Accidents 1,T, _J- Office of Investigations Lafayette City Center t 2 Avenue de Lafayette, Boston, MA 02111-1750 'M - 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.ElWe 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 ce the ins and penalties of perjury that the information provided above is true and correct. Signature: '7' " '4 - 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 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia