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Home My WebLink AboutBLDP-21-005445 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 3122121 PERMIT# BLDP-21-005445 JOBSITE ADDRESS 18 CANVASBACK LN OWNERS NAME DAVIS PAUL F SR P OWNER ADDRESS DAVIS ANN E P 0 BOX 174 LYNNFIELD,MA 01940 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:❑ RENOVATIONS,❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El 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 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❑ 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 1P298 SIGNATURE MP 0 JP 0 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 WORK sm5mo e_ Y _ —� r`A " 1` MA DATE I3 j 19 /CI1PERMIT# �' ` -?-1-- 0v still E ADDRESS COv/ s L OWNER'S NAMED_ .ac.. ._.�..i n if 1 5_ _...,,,-. r---I P OWNER AD DRESS t t TELj ')Q---- 92 - I7diFAXL____ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIAL V PRINT CLEARLY NEW: s-.„I' RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES Li NO(. _! FIXTURES -- FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ma mum Emilia._ _ ..-.._�1.-1L._-„._ CROSS CONNECTION DEVICE Will 1 ilins DEDICATED SPECIAL WASTE SYSTEM -- rill _ i L_ DEDICATED GAS/OIL/SAND SYSTEM WW1 __. ____ 1 — i , _ DEDICATED GREASE SYSTEM L l [— 1 I I DEDICATED GRAY WATER SYSTEM Lu L I . 'Il im—_-I ..I __ . . ti [ rw mi DEDICATED WATER RECYCLE SYSTEM �W11[ :I I .-.« - 1.- -..- DISHWASHER FM __-_� i .-__ 1�—F-hC DRINKING FOUNTAIN �� ___-J�__-1�-� i 1 i�'IAI Will FOOD DISPOSER ^..L �-- = � I�A�' r I t FM'M I � il !l '�-- FLOOR/AREA DRAIN � C-----, ■- - MTMFN INTERCEPTOR (INTERIOR) II _. L _ , L_ I -- M - 1 -- -- --- - � -- KITCHEN SINK �^ ----. jiiiiiiii iiii MN iiil �, LAVATORY MOM 1 iliffilltillill \._.") ROOF DRAIN 1111111111 I _ 1,, i:. �: SHOWER STALL I_f_I t. Lif l '! 1( 1 1I ( '( um 0. SERVICE / MOP SINK IIIIIIIIIIIIIIIIIIIIIIIIEIIIIIFIIIIEIIIIIIIIIIIIUIIIIIIIIIIIINIIIIIIIIIIIIIIIIIIIH TOILET =NW _ i M URINAL Il_ :_._.:- I . iMII MMIM WASHING MACHINE CONNECTION —= __. II- ? I 1 1allIMI E WrilliMill WATER HEATER ALL TYPES 11 _1I __ Ililiell MIMI. L J 1 IMMIMMI WATER PIPING — inumMUNNIIIMIMMMINIIMMIWimilININSIII OTHER I - _ __ _ . _ w Il ' lwommgmmtmmIMMMIIITMMM r _ . IIIIIIIIIIII , _ _ . _ OIIIIIIINIMIININIIMINNIMFMMFMINIIIIIIIOIUINIIIIIIIIIIIIN __. ._ ,:_____ . �_.z.:.-. -_. LI I _ I SMNIIMIlmit INSURANCE COVERAGE: Os) I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES L:] NO Li mm` IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L1 OTHER TYPE OF INDEMNITY Pi BOND I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the c----,c Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT Ell 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 bbst 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 proiisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,� , -, PLUMBER'S NAME STEPHEN WINSLOW LICENSE # 112298 I SIGNATURE MP71 JP ,� CORPORATIONLi# 3281C PARTNERSHIPLi#L.__ILLC _)#._____________ COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 18 REARDON CIRCLE I CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 I CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM G V Zic) r‘r • The Commonwealth of Massachusetts Department of Industrial Accidents ;I: egAO- I Office of Investigations • Lafayette City Center — =' 2Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le ibl 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: 1.0 I am a employerwith 90 Business Type(required): employees(full and/ 5• ❑Retail or part-time).* 2.❑ I am a sole proprietor or partnership and have no 6. Restaurant/Bar/Eating Establishment 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 no employees.[No workers' comp.insurance required]** 10.[]Manufacturing 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#I 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#I. 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.#1909A Expiration te: 21 Attach a copy of the workers'compensation policy declaration page(showing the policy number0and 1/2 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' /ee the ins and penalties of perjury that the information provided above is true and correct. Signature: %+d.• /,.w. 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): • 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: