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Home My WebLink AboutBLDP-22-000323 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK tVL, CITY YARMOUTH MA DATE 7/19/21 PERMIT# BLDP-22-000323 JOBSITE ADDRESS 9 FOLLINS POND RD OWNER'S NAME james sherman P OWNER ADDRESS 9 FOLLINS POND RD YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:0 RENOVATION:El REPLACEMENT❑ PLANS SUBMITTED: YES❑ NO El 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 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER 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 El OTHER TYPE OF INDEMNITY El BOND El 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'S NAME Stephen Winslow LICENSEI112298 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY SYARMOUTH 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 Q_�;E�_ CITY .,,_.,_.�_ o-rTfN1oV ..,�..c 1 MA DATE -7 i' y Z I ' PERMIT# B -O 12 0603Z r - pus / JOBSITE ADDRESS 661q.01,j_k J l n e(t .611 OWNERS NAME Jai 51I1 7±f& i pOWNER ADDRESS ,. .! ...___..--.___...-..._ ..._,......__„_._.. .._____, .. TELOCOJFAXJ 1.__________. TYPE OR OCCUPANCY TYPE COMMERCIAL Di EDUCATIONAL 0 RESIDENTIAL M PRINT CLEARLY NEW: Er RENOVATION: 0 REPLACEMENT: _.__ PLANS SUBMITTED: YES D NOi-, FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB pm mit �_ a _ ,_ ?� .I --� • MIL l°— �' �� _ _- , _. ';+—y-�_-•a �' •.._�A ar-s-._ ..... ..._.r -.... �1 gig ' -r+e+._ I - it u 1, .� CROSS CONNECTION DEVICE l-_.. '- _, - -: .•_•:: •_.. __-_ •-. ; ,. .J - ` - X 1 ' -.• DEDICATED SPECIAL WASTE SYSTEM L.-., . _•__; _-_ _- I...-_-_--. �;_... L� �Q-- R DEDICATED GAS/OILISAND SYSTEM '�nuMMIparlirig _ _ i �, DEDICATED GREASE SYSTEM ._ _- h.__.-•__ _-_- ;r-_y_' - •- • .- �� .. . - .�-- .— :, lilt ____ __-,M. _:_,M1 DEDICATED GRAY WATER SYSTEM ___ I __I __ — DEDICATED WATER RECYCLE SYSTEM . _ I, ! DISHWASHER a I : • DRINKING FOUNTAIN I1 __-__A _._ti._, 1I, L .: 1 ,:`L�1,. L::,. .;J L� `�LJ L.r-__ FOOD DISPOSER 11 11r 1II I_ ._-�=_ - - � -.i- _ ._.f��-fit`••_ - �-i__—_-• 'zl --_.+..2--�.5.L— la��=-+ ---..--•�� --'�—.... I _ __ . FLOOR/AREA DRAIN -:J °1L---.-T L_.__-T L �- _, =L J L--�=_J L•� L�_ --_- —�L t-.F�.•r.. - ��-- M.-_=:—=ti-. �— u�� ry .`_--ter^.= INTERCEPTOR(INTERIOR) I - _ 1 L -..'�•L_.-��- -I '�_- L, -. ---.- ' -.r-- ,L __ -�- - - �� - KITCHEN SINK j' • __A,.. .1, _ ~JE __.___.._ .__. —�.a�. .._--,T ,.+cam... _ _� -+_r=�. L_ __ - __ __- _ - LAVATORY = -I = -1 = . •ititgilaiiiiiiiiistoilinimpow _ -- --I _ ' i - 1 1 ______1 ROOF DRAIN °-_ _tr. - _- - - _- _= _ - -; rL --•-- ._. _... _ SHOWER STALL L----- J . 1-. -_,I u ; JF -.....J I _- -- '3y� SERVICE / MOP SINK ' 1 _ __I _____: TOILETH _ '� ' �..�., l h ' ' URINAL !( i WASHING MACHINE CONNECTION --- - --„I, .__. . _$. _ - _ • -_ _ - i__ A._ ' - -- ''_ -_ - .....-1 _• -1 .- . WATER HEATER ALL.TYPES r o __ -- - -- -- - - _ _ ' _ __-_-.-. - —__ WATER PIPING = g ..._ - � . ..---- ----- - -- - - - - --- �`� - -gig---- ` - -' -__--' ---- OTHER - - - -' J - - _1.001111 .0illiMIL___- an - _-- . ._ — Ai _ --' ._ _ , _— Lim um INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO L_.. IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [7 OTHER TYPE OF INDEMNITY , „.i 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. CHECK ONE ONLY: OWNER 0 AGENT El SIGNATURE OF OWNER OR AGENT d I hereby certify that all of the details and information I have submitted or entered regarding this application are true our 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 co ling with) li ertine proYision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME PTEPHEN WINSLOW -1 LICENSE # 12298 SIGNATURE MP FA JP .- i CORPORATION -„_i # 3281C PARTNERSHIP. _I #L ; LLC U# _,. -r- . _ �, COMPANY NAME E.F. WINSLOW PLUMBING itHEATING __IADDRESS Lv REARDON CIRCLE I I:: v' CITY SOUTH YARMOUTH TM ISTATE LMAI ZIP f 02664 � ~��—~ -1 TEL I8-394Th , 1 FAX � 08-394-825610ELL IN/A * EMAIL INSPECTIONS@EFWINSW.LOCOM I--_.....— ^1 v S,. The Commonwealth.of Massachusetts �i Department of IndustrialAccidents u,; t l Office of Investigations ••tt Lafayette City Center MI'maO ' 2Avenue 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): 1.0 I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.I I 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.[1 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 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: 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$1,50D.00 and/or oneyear imprisonment, as well as civfpenaltiesin the form of a STOP WORK ORDER and a fire 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: '�--' %'__..L.- 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): 1.JBoard of Health 2.0 Building Department 3.E City/Town Clerk 4.'incensing Board 51E1 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia