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HomeMy WebLinkAboutBLDP-22-003361 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 12/13/21 PERMIT# BLDP-22-003361 I JOBSITE ADDRESS 1 JIBSTAY RD OWNERS NAME LIFTMAN BARBARA S P OWNER ADDRESS 31 BLITHEWOOD AVE UNIT 1206 WORCESTER,MA 01655 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES FLOORS—. RAM 1 9 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 2 ROOF DRAIN SHOWER STALL 2 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING 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 El NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ 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 1Q298 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY 5 YARMOUTH STATE MA ZIP 1026641207 TEL FAX CELL EMAIL linspections@efwinslow.com C; £A./ — . 7 -L vU3 36.7 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES (7& !z41--)12( L--ffr Yes Na THIS APPLICATION SERVE AS THE ❑ FEES$ PERMIT# PLAN REVIEW NOTES 4 S MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - s° = CITY �rw+u �dl`S MA DATE 6 — (o — ' Zl PERMIT # 2-2- " 33 (..'i OWNERS NAME JOBSITE ADDRESS Lj �; 5 ........ ja _ ' &keNivno; L.;�Tr►.,,44u POWNER ADDRESS TEL s'a 6 _ $6, y - yo70 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL —I RESIDENTIAL ff. PRINT CLEARLY NEW: L 1 RENOVATION: Ev REPLACEMENT: LH PLANS SUBMITTED: YES NO© FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB F: Ell CROSS CONNECTION DEVICE RE 11 L 1 ! __ _,,, _„_r DEDICATED SPECIAL WASTE SYSTEM 1 I I DEDICATED GASIOILISAND SYSTEM 1 Mill EMI IIIIII NINO INN IIIIIII APN NM NMI DEDICATED GREASE SYSTEM I I ff ,, , -- ,-- ....„,,,..r. DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM __ , II . 11 ill II .1I li 3I DISHWASHER y . DRINKING FOUNTAIN j. _ _ - .__ ..—mow. FOOD DISPOSER il 1. 11 -.. FLOOR / AREA DRAIN , rI _11. ' MIMI _ . f 9 INTERCEPTOR (INTERIOR) I 1° _. __ 111111 KITCHEN SINK IL ----, L r _ �--�--if LAVATORY . ; L, . 111111«aC---..�_. ROOF DRAIN NW MIN aliiI r--- 11111 Mil. MN NMI 1 /- SHOWER STALL , a, tm.IveS 1111111411E1111M mIIimp SERVICE / MOP SINK111111111111111111111111111I 1111111111111111111 I _ TOILET 1111111.2111111.1MINMIffilligi URINAL 1 1� WASHING MACHINE CONNECTION _ I Jr_ 1 WATER HEATER ALL TYPES `'r NNE NMI 111.1111111111 WATER P I P I N G 11111111011111111111111111IEM ManI111111I111111I Iliiiiiiniithlin OTHER 1111.11111111111111111111111111111111I MN y ` Will NM 111101111111 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES n NO J IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' ' OTHER TYPE OF INDEMNITY 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. CHECK ONE ONLY: OWNER _„I AGENT i , 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 li with II ertine pro'isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i PLUMBER'S NAME STEPHEN WINSLOW LICENSE # 112298 i SIGNATURE MP v JP CORPORATION 71# 3281C PARTNERSHIP 1#[ LLC ,# s I COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS I 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX `508-394-8256 i CELL I N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 9 v , Office of Investigations Lafayette City Center 1'��f 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 90 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.❑ 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: City/State/Zip: Policy#or Self-ins. Lic. #1964A Expiration Date:01/01/2022 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 ' e the ins and penalties of perjury that the information provided above is true and correct. , / Signature: Y -- -.»--!^- Date: 01/02/2021 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): I.❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.0Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia