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HomeMy WebLinkAboutBLDP&G-23-004940 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ;r CITY YARMOUTH MA DATE 3/8/23 PERMIT# BLDP-23-004940 ria JOBSITE ADDRESS 26 ZEPHYR DR OWNER'S NAME OLIVERI DAVID R CO-TRS P OWNER ADDRESS OLIVERI CATHY R CO-TRS 14 OLD BOSTON TURNPIKE HUBBARDSTON,MA TEL 01452 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑v 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 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 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❑ 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'S NAME Stephen Winslow LICENSE W298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# 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 inspections@efwinslow.com op- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes Na THIS APPLICATION SERVE AS THE El ❑ FEES: PERMITS PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK s. Yarmouth MA DATE ' 2IPERN'HT # CITY j �3/61 3 JOBSITE ADDRESS L26 Zephyr Drive 1 OWNER'S NAME[David Oliveri P OWNER ADDRESS 'sameI TEL 508-2549224 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL RESIDENTIAL R PRINT CLEARLY NEW: ,1, RENOVATION: _ REPLACEMENT: �y PLANS SUBMITTED: YES ____ NOE FIXTURES Z FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1► CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM j �! DEDICATED GAS/OIL/SAND SYSTEM _ EMI ,, --- ---1111111 DEDICATED GREASE SYS _ i I �- - I i ; DEDICATED GRAY WATE' *. EA>4.... ,� : .�... ... , f! li DEDICATED WATER REC 4CLE SYSTEM ' f j I If DISHWASHER - _ _ $' 11111 MIN MI ` DRINKING FOUNTAIN -- FOOD DISPOSER ° ;M _� — _� FLOOR /AREA DRAIN l INTERCEPTOR (INTERI•' f . _ - , 1 L ! KITCHEN SINK I ' 7 LAVATORY a -__i NM INN 11111 EMUANN M;'� ROOF DRAIN ilia , i ry l' is _. SHOWER STALL Ii r i SERVICE I MOP SINK -r . ., _ TOILET ! I' 11 _ I' URINAL 1111111111111111111111111111111111111111111111111 WASHING MACHINE CONNECTION Iti_ ..._ .: ....:......w. WIN ., . ... I— 7, iI _EN .. WATER HEATER ALL TYPES ' 1. _ WATER PIPING _ �. ,. OTHER, _ i , °I I1 ! 1 - , miamimilimeaminiiimmnin j INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES it I NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1 OTHER TYPE OF INDEMNITY I 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 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 co li. : with II ertine pro' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW 'LICENSE # [12298 SIGNATURE MP , ' JP J CORPORATION Ld# 3281C PARTNERSHIP[J# LLC # _1 COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY[SOUTH YARMOUTH STATE MA j ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents ,9 Office of Investigations iw4' j Lafayette 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 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. 0 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 *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�nrd penalties of perjury that the information provided above is true and correct. Signature: `^\ r 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.['Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK b CITY YARMOUTH MA DATE March 08,2023 PERMIT# BLDP-23-004940 JOBSITE ADDRESS 26 ZEPHYR DR OWNER'S NAME OLIVERI DAVID R CO-TRS G OWNER ADDRESS OLIVERI CATHY R CO-TRS 14 OLD BOSTON TURNPIKE HUBBARDSTON MA 01452 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL ID 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 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/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 © OTHER 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. PLUMBER-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP❑ MGF © JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# 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 inspectionsta7efwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - _ ':WI: - CITY Yarmouth{ MA DATE 3/6/23_- PERMIT # ,,�/� Z3 - v0Lii v - _ . _ , .. JOBSITE ADDRESS 26 Zephyr Drive I OWNER'S NAME David Oliveri I GOWNER ADDRESS same TEL 508-254-9224 I FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 14 BOILER - � .._._.. BOOSTER ti CONVERSION BUR z _ COOK STOVE Kt DIRECT VENT HEA } c•.� F DRYER fit ' 00 , FIREPLACE - _ FRYOLATOR 0 10 FURNACE i M ; a + . GENERATOR 5 GRILLE m INFRARED HEATER _ _. LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER _ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER • UNVENTED ROOM HEATER WATER HEATER 1 OTHER I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES v NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v 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. 0 ......01, PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP V MGF JP JGF LPG!Li CORPORATION ;# 3281 C ' , PARTNERSHIP #_ LLC #7,..-= COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE ..... ... ............. _ .....,....,.......... ... -3.....„.•^."9.. aWs..:,,,,...:-;lm.los.t w;).. K&?aYS4n..8remw'S..t:.t'4fa a.a)2 ir::.:::........ CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 ] CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM it , ` The Commonwealth of Massachusetts ' . Department of Industrial Accidents �9 ,' Office of Investigations _' Lafayette City Center V 2 Avenue de Lafayette, Boston, MA 02111-1750 -f 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]** 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 cer • and the ins penalties of perjury that the information provided above is true and correct. � � -''- ....Di__ Date: Signature: ?' 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.❑City/Town Clerk 4.❑Licensing Board 5.❑Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia