Loading...
HomeMy WebLinkAboutBLDP&G-23-005205 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Dpiy fu CITY YARMOUTH MA DATE 3/22/23 PERMIT# BLDP-23-005205 !I J JOBSITE ADDRESS 24 HIGHBANK RD OWNERS NAME MCDOUGAL JOAN C P OWNER ADDRESS 24 HIGHBANK RD SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO El FIXTURES 1 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❑ OTHER TYPE OF INDEMNITY El 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 19298 SIGNATURE MP El JP El CORPORATION ❑# _ PARTNERSHIP ❑# LLC ❑it 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 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,;1-- --=.....1107-=1 SZDP-23- .5-2Y 7.:Fit,..kiw CITY !Yarmouth MA DATE 3116/23 PERMIT # JOBSITE ADDRESS 124 Highbank Road OWNER'S NAME Joan McDouQhal i re OWNER ADDRESS !same TEL 774-212 7476 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL -1,1 EDUCATIONAL 0 RESIDENTIAL PRINT ���� .._I PLANS SUBMITTED: YES NO CLEARLY NEW: �, RENOVATION: �..w-� REPLACEMENT: ��..v.�; ,. .a._, FIXTURES Z FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB IMIIIIIIIIIIIIII CROSS CONNECTION DEVICE !WM, _ , -1 - , 1 .._ I DEDICATED SPECIAL WASTE SYSTEM 111.1111.11111 MI an p am am Mil" I DEDICATED GAS/OIL/SAND SYSTEM 'I I It_I I.1M11111.11111111111111111111111111111111NMinig mii am DEDICATED GREASE SYSTEM I 111110110111 N I DEDICATED GRAY WATER SYSTEM 10111101111 MI1INN MIINI11•111111111111111111111111111111111ICINMI 1111111 DEDICATED WATER RECYCLE SYSTEM Iam oni aimaggiI.I I mociiimimmmin mil a NE um DISHWASHER 5 ___ , I , __ .._ __ I ....._ _ DRINKING FOUNTAIN ?t. ._. _ i ' _ . ._. FOOD DISPOSER imilini MN1.IIIIIIMIIIIIIIIIIIINIIIIIIIIIIIIIIIIIIIIIIIIMIIIIIIIIaINI FLOOR /AREA DRAIN NOM 1111111111111111111111111111111111111I , ., MO... INTERCEPTOR (INTERIOR) � NI _ � 1 ' KITCHEN SINK MN Mt _ �E - : LAVATORY ® _..____ _ f{ ROOF DRAIN NE INS OMNI IllinnirMIIIIIIIIIIIIIIIIIIIIIII I SHOWER STALL illIMI 111111111111111111111011011 i1101111111111111i [ iUN MIMI SERVICE / MOP SINK h1 _M . I i i /. 1 TOILET URINAL MIMINIMINIIIII 1---It WASHING MACHINE CONNECTION III — WATER HEATER ALL TYPES MiliniaMMIIIIIIIIIIIIII INN 11111(111111111111111111111111111M MINI WATER PIPING MalliIIIMIMIIIIIIIIIMIIIIIIMEI 111111111111111111111110•111111111IINN Mil OTHER _ _ him MI 1 i UN Ell INSURANCE COVERAGE: I have a current Iiabilit _insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [J NO Li IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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. CHECK ONE ONLY: OWNER __ . AGENT j _ SIGNATURE OF OWNER OR AGENT I hereby certify that all cf 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 5 with II ertine prqsiy,of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I STEPHEN WINSLOW _..M._......mm _____ JLICENSE # i 12298 SIGNATURE MP ; JP CORPORATIONS# 3281C LU# PARTNERSHIP ._..._ #i LLC [ 1 COMPANY NAME E.F. WINSLOW PLUMBING & HEATING 1 ADDRESS 18 REARDON CIRCLE CITY[SOUTH YARMOUTH STATE MA ` ZIP 02664 i TEL 508 394-7778 FAX 508-394-8256 CELL N/A , EMAIL INSPECTIONS@EFWINSLOW.COM .,.._ . - __ --- - - = The Commonwealth of Massachusetts Department of Industrial Accidents 9 . `______„9 Office of Investigations �l'=° Lafayette City Center izi 2 Avenue de Lafayette, Boston, MA 02111-1750 °iM(. . 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 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]** 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 cen(� the �invs��nrd penalties of perjury that the information provided above is true and correct. Signature: ` Y 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.DBoard of Health 2.0 Building Department 30 City/Town Clerk 4.0Licensing 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 YARMOUTH MA DATE March 22,2023 PERMIT# BLDP-23-005205 JOBSITE ADDRESS 24 HIGHBANK RD OWNERS NAME MCDOUGAL JOAN C G OWNER ADDRESS 24 HIGHBANK RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES 0 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 LI 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 at plumbing work and Installations performed under the permit issued for this application wit be in compliance with at 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 0 JP❑ JGF❑ LPG! El CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 J TEL 5083947778 FAX CELL EMAIL inspectionsWefwinslow.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 100. CITY Yarmouth I MA DATE 3/16/23 J PERMIT # JOBSITE ADDRESS 24 Highbank Road 'OWNER'S NAME Joan McDouahal OWNER ADDRESS same TE1 774-212-7476 VAX.. TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL Ld PRINT CLEARLY NIEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES NO LA APPLIANCES I 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 ..._.. samit FURNACE I 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 I . INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YESv 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 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 SIGNATURE OF OWNER OR AGENT 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. r PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP MGF Li JP JGF LPG' Li CORPORATION # 3281C PARTNERSHIP # LLC # A COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARIvMOUTH SATE MA ZIP[02664 JTEL 508- ' '7EC_ E I V E D , .0; FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM BUILDING DEPARTMENT By' (", The Commonwealth of Massachusetts _ Department of Industrial Accidents 13 --,,,9\ Office of Investigations Lafayette City Center 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.❑ 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 ce • of the ins and penalties of perjury that the information provided above is true and correct. �f/ Signature: Y " . -� 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 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Se1ectmegs Office 6.DOther Contact Person: Phone#: www.mass.gov/dia