The URL can be used to link to this page

Home My WebLink AboutBLDP-21-003760 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,�0 CITY YARMOUTH MA DATE 1/7/21 PERMIT# BLDP-21-003760 4�„.�_� � JOBSITE ADDRESS 21 OLD CHURCH ST OWNERS NAME DOBEREINER NIGEL 0 P OWNER ADDRESS DOBEREINER CATHY A 15 CLARK RD FISKDALE,MA 01518 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:El 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❑ 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. PLUMBERS NAME Stephen Winslow LICENSE 1Y2298 SIGNATURE MP El JP ❑ 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 ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING 'D f. WORK — v g CITY __v. A , 1.��.�,..�,m.-. .-�-.' _,.._.........i MA DATE II ► �D &IV-21-03137(c :,.,�,,,e G .Z� ` �_- __ PERMIT# 1111 JOBSITE ADDRESS alffiflh )fc OWNER'S NAME ` uaLC 1 ....„,._.....,,,v,, OWNER ADDRESS LLialark RJ t k J I �,, �.�_._.� Y: TEL 5 . _.56 JFAX[ TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL PRINT RESIDENTIAL[� � CLEARLY NEW: Ej RENOVATION: Li REPLACEMENT: . - PLANS SUBMITTED: YES El NO FIXTURES 7. FLOOR---► BSM 111 3 4 5 6 7 8 9 10 11 12 13 BATHTUB 14 CROSS CONNECTION DEVICE �_ � ��,., ', I,-- �r�MIl `_. M I _.-„� DEDICATED SPECIAL WASTE SYSTEM � � � �� DEDICATED GAS/OILISAND SYSTEM litanang" � _.__ ill� • DEDICATED GREASE SYSTEM {— -- alli l �h - DEDICATED GRAY WATER SYSTEM .Dr. EDICATED WATER WATER RECYCLE SYSTEM1[01l DISHWASHER III ( ift{ _.i , i''{ !_ ; DRINKING FOUNTAIN � M � II lumtl l l- - AIM M ._ . HH- - IFOOD DISPOSER 1 IO — i {AREA DRAIN �I1 � --�� -----, I M-- �!�� I ( twiriNIIIMIM INTERCEPTOR(INTERIOR) I�.I� (�-- i � y' ,' , t KITCHEN SINK - -r ��I I� _{� ��- � LAVATORY i �M ,� � j � � ROOF DRAIN i�llL r I 'I 1IIMRIIIEIIIIIIIMUIIIIIIIIIIIRIBIIIIFI i- f 1111 SHOWER STALL _ � ( 1. C; 4 , _-� _ -, Ir a , SERVICE 1 MOP SINK {_�._r.__._. — " Ili :.- .' - -�; . iI II _. . '�_ . . �ca -�- -- TOILET { � �I {1_ 1 Ii it I URINAL � L-iJV; Si,i IMI , �'Millei I I�fl 11 ll i Ii Ilitrii "� l jl l WASHING MACHINE CONNECTION �--- �� WATER HEATER ALL TYPES I � I; 41 ,l I� _ is � ( WATER PIPING Iligr r � I EIRIM � I- , OTHER -.-�.- -_ - -- ---- � ram' - G MGM _ 1 1 � _i_ :„,.:.�.,H , _ imi !a_Cr l _ if it 1 I II RIEtionlitilimili INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES �._ '' NO I,,,A IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITY iii BOND C yJ 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 I.�.Ji AGENT ( l 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 st of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be in co II wit II ertine pro\rislo of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. n PLUMBER'S NAME STEPHEN WINSLOW L CE `J NSE # 12298 j SIGNATURE - I MP 71, JP CORPORATION 0# 3281C PARTNERSHIP)#1„ w - ; LLCI #L COMPANY NAME E F. WINSLOW PLUMBING & HEATING ' ADDRESS 8 REARDON CIRCLE �_ V `-' CITY SOUTH YARMOUTH STATE MA ZIP 02664 • TEL 508-394-7778 r� - FAX , 508-394-8256 CELL N/A EMAIL INSEECTIONS@EFWINSLOW.COM r The Commonwealth of Massachusetts • Department of IndustrialAccidents _,yTF Office of Investigations Lafayette City Center — �= 2Avenue de Lafayette,Boston,MA 02111-1750 zoo 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. 0 Retail or part-time).* 6. 0 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 area 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'compensationpolicyinformation. **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 car //7J'the ins and penalties of perjury that the information provided above is true and correct. Signature: % h-. (/.««.( 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): iUBoard of Health 2.❑Building Department 3J:J City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: