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HomeMy WebLinkAboutBLDP&G-21-005697 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1=:49fiA_=a� C.=;tiro _D CITY \u inc.t f._ I MA DATE .,;/.:.Z yZZ I PERMIT# �b P -1l -00 S 6�17 r _. JOBSITE ADDRESS I .7 Fit/ L.(p,,7. �>FYr,n j/11 1 OWNER'S NAME ,Ica,/413..&wc zl� OZE 73 OWNER ADDRESS _. ✓ll-_,. _. .-_._ TEL ?d`5, 74ZG_ FAX-_ _.. TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL L PRINT r-� / CLEARLY NEW:Q RENOVATION:0 REPLACEMENT:L PLANS SUBMITTED: YES U NOD FIXTURES 7 FLOOR--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I j CROSS CONNECTION DEVICE 1, 1 IF 1 1 I II ( _ ' DEDICATED SPECIAL WASTE SYSTEM f I ,! 1 11 _, : L11tUJ1IiL1.AY WATER SYSTEM op iUlJIta - -Hsi11115_. ' I ' DEDICATED WATER RECYCLE SYSTEM l DISHWASHERimi DRINKING FOUNTAIN _ ,EtHRI @ 4 ' _ i -_.. FLOOR/AREA DRAIN I , ,, INTERCEPTOR(INTERIOR) ! _ KITCHEN SINK i a: 6 I r LAVATORY II I ` __ .:- __ !iI!flhi ROOFDRAIN i1 SERVICE/MOP SINK - URINAL _ ._ i NER_ :R___ WASHING MACHINE CONNECTION i I i I I WATER HEATER ALL TYPES _ i _ II WATER PIPING OTHER , `I I 1 II � - _ I__ I� -- - - I 1 z : INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES El NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY +: OTHER TYPE OF INDEMNITY Di BOND ri 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 0 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 co li with II ertine pro'isio of the k Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - ..•.p "....- PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP El JPLJ CORPORATION 0# 3281C PARTNERSHIP I#[ iLLCTI# _. o COMPANY NAME' E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE '_ �- CITY!SOUTH YARMOUTH STATE MA ZIP 102664 ] TEL 508-394-7778 FAX 508-394-8256 J CELL~N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents N ` „ Office of Investigations „moan — Lafayette City Center il— ` 2 Avenue de Lafayette, Boston,MA 02111-1750 s°°'�� 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 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.❑ 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$1,500.00 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 ylz ss�and penalties of perjury that the information provided above is true and correct. Signature: . 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): 1.0Board of Health 2.❑Building Department 3.0 City/Town Clerk 4.❑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 YARMOUTH MA DATE April 02,2021 PERMIT# BLDP-21-005697 `' 4 JOBSITE ADDRESS 17 FLUME CT OWNER'S NAME BEAUCHEMIN ROBERT L(LIFE EST) G OWNER ADDRESS BEAUCHEMIN KAREN P(LIFE EST)17 FLUME CT WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO 0 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 ❑ 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# 12298 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc 0# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsRefwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY 1 FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El El FEE$ PERMIT# PLAN REVIEW NOTES - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e... r Ally CITY �._..._..._-- - -T - I MA DATE j/I ,:/ .. ., ' PERMIT# i L O & `L(-bit “, 11 JOBSITE ADDRESS[araLug.Lud, ,r s ; cage a tltia, OWNER'S NAME lloreetlegkcjif. ,_rYl GOWNER ADDRESS G�i�'le, P TES i s1S-7 FAX.:saa� � loon,.r-rn .n .•_,_-___ .. ..... .. _..... TYPE OR OCCUPANCY TYPE COMMERCIAL ,_ I 'i PRINT EDUCATIONAL I�_ RESIDENTIAL CLEARLY NEW: u RENOVATION: . .i REPLACEMENT: L.. PLANS SUBMITTED: YESLI NO[... APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1R. .13 i E- "{-7 _• 1 (.. '._. E--- 7. I-^_. .�.._,_.�.. ^t.7___.._...,i.�.�...._„]1�..__ -_i r..-�.F E:77, BOOSTER �,�,�.��.._.s� •I� r[ . _ i l.. . .. F ._ �,1--__.�,1. '.(1 1. .. . I'- T-. . r .... :1 CONVERSION BURNER L.— ; Eli: _._.._-_E�. _.. . -'' T__ _...... -_1 __-_-; _ - -_ COOK STOVE1,______! It. I � ,----�--- ------- -----; --------- i--- _..--,�-----=---.-;-== I---=-- - -� _ 1� V' _____- Ii. I _- ,---- ... _-_i L�._• - I--_.-•.- i--•----- -- ! I_-_-__ L____i_..___i l—_- [I . DIRECT VENT HEATERi �_ �_�.__._! __. 1�__ _I I I, �_ - __... T' - `�' i° r DRYER [,..___731-- 1. _ J;E_.__.___I 1 I I�_.-J�I.-_.-T_ 1 r---. (- u 1_73[—- L 1:[-_--_1C._117T FIREPLACE T _ -1---1 _. s -.- . _ _ . ._ _ I .. , __.7( ... - . [ . . ... - �;-- -- I --- I- I FRYOLATOR E _ _IE- :1 TI _ L I ' --- ' i. _ E.__ 1 . '� 1 _ 1. FURNACE E-. iI �� ..[ . 7w�'I _ �j ._�� � ^ -- I �.__ � _I _ -r GENERATOR _ I . .- _ I-__- I_._...71-- 11_- E_ _ :7 _ _f _ __1 I _ GRILLE -- l- ___ ' TL—:11_ - - —7I----_1-_ - --_ 1-=I` L � — Bil INFRARED HEATER [ ,, -..., _ - --- - [ . - - - _- - ___..- . . _` _-___. I'I --! I- --21____ E 1E - LABORATORY COCKS 1 II,_..___.__I 1� _ _ -_J _- _ - _____ _ i1 - � i- 'i ! MAKEUP AIR UNIT ..� :f .' 1-� -'1 . � ' _ 1.1— =i�L_ `1� ._Y E ___ 111.---. - _ 1..-- 1_{- ___J _111 I. OVEN -��- `-� E I L i. E� I IJ I (11 J __._ ._.. L__-_1' _-___.;1=1—-,E1.►1 POOL HEATER 1 _.-E _-' I -_ _-._J -._ _ 11—D .__ _' L___1 1...___+` �,�_I.1-__-�L ` L ;']_ _i [ _I l_._.._ ` E HEATER �� � -` ROOM SPACE L.r�._I 1. --- -1.1,____--i` �:.: E---I,- •—_i�1.. _ ..i�____-- E �'1__1 .I: ___._11__—i`,_ __.r11-_.--1:I--_-i ROOF TOP UNIT I �. �I I -i E^. 3.1_-----i�1_ J�Ei-__ ll i'l ?; I I_ 'I. -__.- �_--_ . -I;C '` TEST E. ,�.._.:..I1. ,I -- Ii1-____-..I L ..Ti _._ _._I l-.T�__ i 1...�-. _ .__1. _�!A _J L_---__111------I i-- --? C_ _ 1. UNIT HEATER __j, ! -;s `' `T'�1 �' �' -_._. � _____. �' h_ __.L__..__. _ 1. __,r I-" I J:L-_. -i;1_ I-.-_��I l 1_. 1' i UNVENTED ROOM HEATER i �( _i J - -I. : E.7 i. WATER HEATER 1 L 1.__ .__._ - --T_I' _ ' i __._.' 1- _I -ir _. _ _ �l_ i a i - OTHER 1 __-_.__..._ , -__ j L __.' E�-�1- --r --Y.,----, ----- ----, , - ^ . -�--- _..r L_ `E� . __ i - I I. .._ _ h __ .. L [ r1 1 __i i s T t_1. � u — iixrqx -— -11.__ 1--- - __ ___ _-- --- Yi _—E: 1: ..1- 1 1. 1 1:-1( _.. ^ E__ ._1 I _ LI--i I: 17.--.i-1.:-=-. ! ___- _{! _ -__i _i _.__�L. is — —1' I J I E hFA".'FwRY]5fi7�RiDWOxatS'SLLMCadSY.�tVCUKiA c3lw:atiB44':aGC1ul1K - -. INSURANCE7-7 COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Ea NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F OTHER TYPE INDEMNITY [i1 BOND L 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 Fij AGENT E DI 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 accurst 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 Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME EIHEN WINSLOW 1 LICENSE 412298 J SIGNATURE MP :.:�--Ji MGF U_--,1 JP El JGF Li LPGI FA CORPORATION , # [ 81C _I PARTNERSHIP #1J LLC LJ#---7. c-- COMPANY NAME:I E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE ..,._____..,____ M - ` CITY YARIV10UTH STATE MAJZIP1O �[SOUTH _OU _.�.�__ -_-r._�- �_� � 2664 ITEL 508 394-7778 FAX 1 1508-394-8256 1 CELL N/A EMAIL INSPECTIONS EFWINSLOW.COM ---------------------w_----- The Commonwealth of Massachusetts Department of Industrial Accidents iii_ 1 i Office of Investigations �' Lafayette City Center W 1/4 2Avenue de Lafayette, Boston, MA 02111-1750 4.No•''' 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. 0 Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. 0 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 *My applicant that checks box 41 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. Lie.#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 gizins and penalties of perjury that the information provided above is true and correct. � 01/02/2021 7' ` Signature: )7// - '- 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): 10Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.11Licensing Board 50 Selectmen's Office 6.[]Other Contact Person: Phone#: www.mass.gov/dia