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HomeMy WebLinkAboutBLDP&G-23-003987 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Ti,r-----)1,-—,..- /a CITY YARMOUTH MA DATE 1/20/23 PERMIT# BLDP-23-003987 F, gi, JOBSITE ADDRESS 11 JOHNSON LN OWNER'S NAME Kathy Downing P OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES NO 0 FIXTURES : FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 0 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 I 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 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. 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 1Q298 SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ISTEPHEN A WINSLOW I ADDRESS 8 REARDON CIR 8 REARDON CIR CITY IS YARMOUTH I STATE IMA I ZIP 102664 I TEL 15083947778 I FAX I 1 CELL I 1 EMAIL (inspections@efwinslow.com I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEESS PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK , ., s•.®� � CITY Yarmouth MA DATE 11/9/23 PERMIT # JOBSITE ADDRESS 11 Johnson Lane OWNER'S NAME°Kath Downin OWNER ADDRESS !same TEL 508-240-4096 JFAXr TYPE OR OCCUPANCY TYPE COMMERCIAL ....W ! EDUCATIONAL E] RESIDENTIAL I �_I PRINT CLEARLY NEW: H ,..( RENOVATION: 1 1 REPLACEMENT: I.e.-e✓.+ 3 PLANS SUBMITTED: YES ?_- NOD FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ______r-._ _mm,_ CROSS CONNECTION DEVICE i { . I i DEDICATED SPECIAL WASTE SYSTEM L . . J L __ IN.- 1 1- DEDICATED GAS/OIUSAND SYSTEM __: IMP .,. 1—w-1 1 DEDICATED GREASE SYSTEM INN OM AMIN 1 DEDICATED GRAY WATER SYSTEM t '' L,.._.... L .. A DEDICATED WATER RECYCLE SYSTEM : II 1 I1.11 MIN MI DISHWASHER N. __ i 1 11111111 _i _ _ .. DRINKING FOUNTAIN p ._..._, ,,...-i ;; ..., ,- .I .._... FOOD DISPOSER I_..______ FLOOR /AREA DRAIN MINIIIIIIMIIIII.110 iii.; , ,: _ . .. INTERCEPTOR (INTERIOR) I KITCHEN SINK ...-1 --1111111111, i_ LAVATORY mu '1 I _ _... ram _ __ _- �.�__.�..o ROOF DRAIN I t 1 'l SHOWER STALL SERVICE / MOP SINK ► `I ) _ -,TOILET { URINAL _ _ - 1 . WASHING MACHINE CONNECTION . _ 1 I '_._. _ 1,y__ „,,.. WATER HEATER ALL TYPES t 1 [7 .._. .: of ,. , 3 WATER PIPING_ 11111111 MP IIIIN OTHER E: .. rH _ .._ . .. .... . . 111111.. � INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E NO El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPR(.". _ BOX BELOW LIABILITY INSURANCE POLICY 1 OTHER TYPE OF INDEMNITY 'i, BOND 1_____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 I 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 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 lia with II ertine proxisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C.,... r .."‘ „pit.. 104......0.0' PLUMBER'S NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE ....] t___ MP : JP ,` CORPORATION „.„ #[3281C PARTNERSHIP _. # ., — LLC ...l#1 COMPANY NAME WF. WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMC)UTH Y STATE MA ZIP 02664 TEL 508 394 7778 FAX 508-394-8256 1 CELL N/A 1 EMAIL INSPECTIONS@EFWlNSLOW COM The Commonwealth of Massachusetts " Department of Industrial Accidents 51) _—+67 Office of Investigations Lafayette City Center t� 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. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.0 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.E 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 the ins and penalties of perjury that the information provided above is true and correct. Signature: c ? "` �-_#/-- 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): 1,1=1Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5J Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ‘7-kliNiq CITY YARMOUTH MA DATE January 20,2023 PERMIT# BLDP-23-003987 JOBSITE ADDRESS 111 JOHNSON LN OWNER'S NAME Kathy Downing G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Q 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 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 0 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 it 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 inspections( 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 k_ CITY Yarmouth 1 MA DATE 119/23 PERMIT # JOBSITE ADDRESS 11 Johnson Lane OWNER'S NAME Kathy Downing OWNER ADDRESS same TELL508 240-4096 IFAXI TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: 1 RENOVATION: r REPLACEMENT: PLANS SUBMITTED: YES NOD APPLIANCES -1 FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BLRNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ` OVEN POOL HEATER ROOM 1 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 v , OTHER TYPE INDEMNITY 1.1 BOND x OWNER'S INSURANCE WAITER: ! 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 cr 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 LICENSE # 12298 SIGNATURE MP MGF Li JP JGF LPG' CORPORATION # PARTNERSHIP r., 3281C # LLC # .1 COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS ' 8 REARDON CIRCLE :..-ik ,W662Ss ..-Y-----kev 4,i 1 -•b2e ,t,.'•io,;AnriF ,.._., 1 CITY SOUTH YARMOUTH STATE i MA ZIP 02664 TEL 508-394-7778 m � FAX ` 508-394-8256 CELL N/A � EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 9 Office of Investigations Lafayette City Center %� 2 Avenue de Lafayette, Boston,MA 02111-1750 `'(. ,. ww».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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.ElWe are a non-profit organization, staffed by volunteers, 11.❑ 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 the ins and penalties of perjuty that the information provided above is true and correct. Signature: 7' '` 4,1 t 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 tBoard 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