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HomeMy WebLinkAboutBLDP&G-23-005086 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1/ CITY 'YARMOUTH I MA DATE 3/15/23 PERMIT# BLDP-23-005086 JOBSITE ADDRESS 50 KEEL CAPE DR OWNER'S NAME SINGER MYER R TR P OWNER ADDRESS MYER R SINGER REV LVG TRUST 50 KEEL CAPE DR SOUTH YARMOUTH,MA TEL 02664 TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El 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 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. PLUMBERS NAME Stephen Winslow LICENSE 1Q298 SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME [TEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 TEL 5083947778 FAX 7 CELL 7 EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ FEES$ PERMITS PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r-- 7- 3 - o(*) 5 oS,(„ CITY [Yarmouth MA DATE 3/10/23 PE RM JOBSITE ADDRESS [50 Keel Cape Drive J OWNER'S NAME Elaine Singer OWNER ADDRESS same TEL 508-385-9228 IFAXL____ TYPE OR OCCUPANCY TYPE COMMERCIAL LJ EDUCATIONAL ri RESIDENTIAL 0 PRINT CLEARLY NEW: I- ] RENOVATION: I,_� REPLACEMENT: PLANS SUBMITTED: YES NO(I FIXTURES Z FLOOR—► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB M,1111 11111111111 1111111111 3 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ill.' DEDICATED GAS/OIUSAND SYSTEM ..::_..� �' I. DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ' tffi DEDICATED WATER RECYCLE SYSTEM DISHWASHER D L . '.I t- 1 DRINKING FOUNTAIN — -- _ _ �. 1 FOOD DISPOSER ' I FLOOR /AREA DRAIN I. Min It_ � r...:1 INTERCEPTOR (INTERIOR) I 1 ar 1r KITCHEN SINK , 1 tt 1 W I LAVATORY II. ROOF DRAIN e,�.. _.:... _.. SHOWER STALL _ _ ._ � - _ ,,,..1, .E SERVICE / MOP SINK w - i ___ 1 r �TOILETL . . .. URINAL . IMO.. - 1 WASHING MACHINE CONNECTION ----1 — 1_, M IIIIINIIIIIIIIIIIIIMIIIIIIIIIIIINIIIIIIIIIIII WATER HEATER ALL TYPES ,1 ,... ;£ WATER PIPING _.__._... _.._ _�_.: i 1 1 .i OTHER 1 _ SISMII ' L. „.„ 11 1 -11 . 11111, 1111 MINI 111111111111111' 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 I v I OTHER TYPE OF INDEMNITY ' I BOND 1 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 [1: 1 AGENT -__' SIGNATURE OF OWNER OR AGENT I hereby certify that all Df 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 ssued for this application will be in co lia with II ertine proYisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME i STEPHEN WINSLOW ]LICENSE # i 12298 SIGNATURE MPH JP11 CORPORATION I # 3281 C PARTNERSHIPQ �# _ I LLC # - COMPANY NAME E.F. WINSLOW PLUMBING & HEATING I ADDRESS ' 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP [02664 TEL 508- 417 FAX [ 08-394-8256 1 CELL N/A 7 EMAIL INSPECTIONS@EFWINSLOW.COM MAR lb 201 —"' BUILDING DEPARTMENT The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations Lafayette City Center Vg 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): 1.1 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]** 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.Lie.#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 ee the ensand penalties of perjury that the information provided above is true and correct. Signature:�tY --'�^ Date: Phone it: 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): 1fBoard of Health 2.1:1 Building Department 3.0 City/Town Clerk 4.0Licensing Board 5:0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' s CITY YARMOUTH MA DATE March 15, 2023 PERMIT # BLDP-23-005086 VW JOBSITE ADDRESS 50 KEEL CAPE DR OWNER'S NAME SINGER MYER R TR G OWNER ADDRESS MYER R SINGER REV LVG TRUST 50 KEEL CAPE DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 F OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 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 plurrbing 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 El LPGI ❑ CORPORATION El # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME: ETEPHEN A WINSLOW 1 ADDRESS. 8 REARDON CIR, 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 TEL 5083947778 FAX ] CELL EMAIL ,inspections(a,efwinslow.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 =` `— G c050 CITY Yarmouth I MA DATE , 3/10/23 PERM JOBSITE ADDRESS 50 Keel Cape Drive J OWNER'S NAME Elaine Singer OWNER ADDRESS same TEL508-385 9228 I FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL' k EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS- BSM 1 2 1 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 i LABORATORY COCKS _ { MAKEUP AIR UNIT OVEN 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 LI OWNER'S INSURANCE WAIVER: 1 am awaie 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 I LICENSE # 12298 SIGNATURE MP MGF ID JP : JGF J LPG' [ CORPORATION 'J# 3281C PARTNERSHIP # LLC # COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YAR V1OUTH STATE ZIP 02664 TEL -5Q8=324= -�-- ft- FAX508-394-8256 CELL N/A EMAIL[INSPECTIONS@EFWINSLOW,COM - -- --�-"1 MAR 15 2023 BUILDING DEPARTMENT \, The Commonwealth of Massachusetts Department of Industrial Accidents ,' ,9 Office of Investigations w _; 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 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, 11.0 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 ' 7 the ins and 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): 1.0Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia