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HomeMy WebLinkAboutBLDP&G-22-005764 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK u) { CITY YARMOUTH MA DATE 4/8/22 PERMIT# BLDP-22-005764 'i JOBSITE ADDRESS 152 KATES PATH VILLAGE OWNER'S NAME Bruce Turner P OWNER ADDRESS MA 02641 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ 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 D 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 tie 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 perrr it 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 1Q298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADCRESS 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 ❑ FEES PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK C� CITY ,..YARMOUTH (PORT) MA DATE 414l22 PERMIT # 1-2— �`1 rx JOBSITE ADDRESS 152 KATES PATH OWNER'S NAME BRUCE TURNER POWNER ADDRESS ` SAME TEL 774 330-3182 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL . j EDUCATIONAL El RESIDENTIAL E PRINT CLEARLY NEW: jr....j RENOVATION: I REPLACEMENT: zi PLANS SUBMITTED: YES , J NOL , FIXTURES 1 FLOOR BSM 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ._-- tl -- : -. IIIIII �.. I ' CROSS CONNECTION DEVICE MiliMillal mintimmu _ [ m a ans omit DEDICATED SPECIAL WASTE SYSTEM IMIIIIIEIIIIUIMBIIMIIIIIMIIIMIOIIIUIIIIIIIELINHNINIEINEINNEINIINII DEDICATED GAS/OILSAND SYSTEM rim ' I min ' 1i -- . 1MM DEDICATED GREASE SYSTEM , DEDICATED GRAY WATER SYSTEM NlaIIIIIIIIIIIIIIMIIINIIIIINNIiilanlaliraIINIIIIIIIIIIIIIIIMIMIIIII DEDICATED WATER RECYCLE SYSTEM ._... ...1= I- __. t _- 1 1 I nal DISHWASHER ........ nit _....... ........ �....... DRINKING FOUNTAIN IIMITIIIIMMWNIFIIIMIIIIIIIIIIIIIIIIIIIIIINIIIIIIIIIIIIIIIIIIIIIIIIIIIIII FOOD DISPOSER IINNIIIIIIIIIMMIIMIINITITOIIMIOICIIIIIIIIMIIIINIMIIIMIIIIIIIIIIIIIIIIMIIII FLOOR I AREA DRAIN 1111111111111111111111111111MUM INTERCEPTOR (INTERIOR) MINIIIIIIIIII IIIIIIMITNIIIMIIIMEMINE1111111111M1111111 KITCHEN SINK 1111110 — LAVATORY1111111.11111111111111110111.11111111111111111111111111111.111111111 ROOF DRAIN Mit MO SHOWER STALL larnill.11.11. 1.. Man MINIM iiiiinni - SERVICE I MOP SINK _ mmC: ' M alli MINIM TOILET _ URINAL - _ im minimum= WASHING MACHINE CONNECTION MIIIMINNIimillitiniiia nu mei IIIIIIIMWIMM WATER HEATER ALL --YPES =NM.11.11111111.1111111.11 WATER PIPING __.-. .._ 11111111.1111111.111111.111.11MININTOOMMUNI11.111111111111 OTHER 1.11111111MIMIIIIIIIIIIIMININNIUMMILMININIMIIIIIIMI 11111111111111111111111111111.1111.111111111111111101.111.11111111111111111111 INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES i ` NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i •' 1 OTHER TYPE OF INDEMNITY BOND f 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 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 e 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 comp li with II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW ____J LICENSE # 12298 SIGNATURE MP, i JP L CORPORATION l# 3281C PARTNERSHIPI # i COMPANY NAME' E F WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY[SOUTH YARMOUTH STATE MA ' ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 i CELL IN/A 1 EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents _m 6 Office of Investigations =E1�_ Lafayette City Center 1 2 Avenue de Lafayette, Boston,MA 02111-1750 �= �' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le;:ibly 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. E 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.❑ 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: City/State/Zip: Policy#or Self-ins. Lic. #1964A Expiration Date:01/01/2023 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 phins�nd-penalties of perjury that the information provided above is true and correct. Signature: Y Date: 12/01/2021 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): 1iJBoard of Health 2.1=1 Building Department 3.1=1 City/Town Clerk 4.1:Licensing 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 • `'�' CITY FARMOUTH MA DATE 'April 08,2022 I PERMIT# BLDP-22-005764 • JOBSITE ADDRESS 1152 KATES PATH VILLAGE 1 OWNERS NAME Bruce Turner G OWNER ADDRESS MA 02641 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL Q PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES❑ NO El FIXTURES FLOORS—s 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 LABILITY INSURANCE POLICY OTHER OF INDEMNITY El BOND ❑ OWNERS 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 El JP JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(r.efwinslow.com S310N M3IA32! N'dld #±Ii J i3d $ 33d ❑ ❑ IIWb3d 3H1 SV S3A83S NOI1VDIlddV SIHI oN saA S310N NO1103dSNI'VNI3 KIND 3Sl d0103dSNI HOA 3OVd SIH1 S310N NOI103dSNI SV0 HOflO MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .4 ` f=,r- CITY YARMOUTH (PORT) MA DATE 4/4/22 PERMIT # S -7(.- Lf JOBSITE ADDRESS 152 KATES PATH OWNER'S NAME BRUCE TURNER ,,„,,,, _ G OWNER ADDRESS SAME TEL 774 330 3182 FAX=,,, TYPE OR OCCUPANCY TYPE COMMERCIAL —I EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: i PLANS SUBMITTED: YES NO APPLIANCES -1 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 _. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES , k NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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 compliant a P rtine provision of the Massachusetts State P umbing Code and Chapter 142 of the General Laws. 0 r ' , ,......", PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP ',,.:3 MGF a JP ' JGF 4 LPGI1T: CORPORATION i '# 3281 C PARTNERSHIP # LLC # COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ACDRESS 8 REARDON CIRCLE CITY SOUTH YARNIOUTH STATE MA ZIP 02664 TEL 508 394 7778 a FAX 508-394-8256 CELL NSA EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 9.:. _,, Office of Investigations l 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. El 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.❑ 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#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. #1964A Expiration Date:01/01/2023 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 �y�en��the ph�ins��nd-penalties of perjury that the information provided above is true and correct. //�1 �j(/ 12/01/2021 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 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia