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HomeMy WebLinkAboutBLDP&G-22-005743 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK y %. CITY YARMOUTH MA DATE 4/7/22 PERMIT# BLDP-22-005743 1 JOBSITE ADDRESS 60 JEFFERSON AVE OWNER'S NAME AULD ARLENE F P OWNER ADDRESS 60 JEFFERSON AVE WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURFS 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❑ 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❑ 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 ❑ JP ❑ CORPORATION ❑8 PARTNERSHIP ❑9 LLC ❑9 COMPANY NAME STEPHEN A WINSLOW ADDRESS 8REARDONCIR CITY SYARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE LSE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES S PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 'A ;' CITY EARM OUT H (WEST MA DATE 4/1/22 _.__. . _ PERMIT # -VI — L S JOBSITE ADDRESS 60 JEFFERSON AVE OWNER'S NAME ARLENE AULD P ___ __ _ i - �.. OWNER ADDRESS SAME TELL 508-771-1065 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL . ..I EDUCATIONAL Li RESIDENTIAL El PRINT CLEARLY NEW: a..11 RENOVATION: 0 REPLACEMENT: E PLANS SUBMITTED: YES , _ NOD FIXTURES -1 FLOOR-0 BSM #11/13 4 5 6 7 8 9 10 11 12 13 14 BATHTUB . . IIIIII INN MI. ;------- al1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM 1€ DEDICATED GAS/OIL/SAND SYSTEM _� L1 DEDICATED GREASE SYSTEM . � r . DEDICATED GRAY WATER SYSTEM J III� II DEDICATED WATER RECYCLE SYSTEM 1 :I ii DISHWASHER : .. . .- _ DRINKING FOUNTAIN I _, I imm r FOOD DISPOSER FLOOR 1 AREA DRAIN IIIIIIIMIIIIIIIIIIIIIOIIIOIITIIIIIIRIIIJIIMII INTERCEPTOR (INTERIOR) aMI LLLH 0 KITCHEN SINK .111111111111.1111111111111111111111111111.1111111111111111M111., .1 LAVATORY L.... _..._ IiiiiiMili ROOF DRAIN SHOWER STALL I I M: M Mill 1____ ___. SERVICE / MOP SINK I_ II M I I-., TOILET 111111111111111111111111111111111111- URINAL g... 1 I _. WASHING MACHINE CONNECTION IM iiiinnaliMil __if _ WATER HEATER ALL TYPES 11110iiimi aitmantommimannalliallitillitillit WATERPIPING....w.__.�.._...._.w__.............__._......._....._..._.._.._._...._. ... mil tom l_ A I OTHER 11111 M Mal I I all II NM 11.1.111 1, _ NM 111.11111111111.1 I ' ._.. w INSURANCE COVERAGE: I have a current Iiabiliinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES p NO _. IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I i j 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. CHECK ONE ONLY: OWNER AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all o`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 Ii with lidertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ETEPHEN WINSLOW LICENSE # ' 12298 SIGNATURE MP; v JP Li CORPORATION0# 3281C PARTNERSHIP �# LC COMPANY NAME E.F WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON CIRCLE CITY I SOUTH YARMOLTH STATE MA ZIP [02664 j TEL 508-394-7778 • FAX I53948?56 ; CELL N/A . EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 1 �' — Office of Investigations — �1�pc 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. ❑ 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.E Other *My 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 ce the ins and 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): 1.DBoard of Health 2.1=1 Building Department 3.❑City/Town Clerk 4.0 Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK j-�` CITY YARMOUTH MA DATE April 07,2022 PERMIT# BLDP-22-005743 JOBSITE ADDRESS ISO JEFFERSON AVE OWNER'S NAME AULD ARLENE F G OWNER ADDRESS 60 JEFFERSON AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 ❑ 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 ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX ]CELL EMAIL inspectionsna efwinslow.com S3LON MIA NVId #1I1A1213d $:33# ❑ ❑ 1IV d d 3H1 SV S3A213S NOI1VOIlddV SIH1 oN seA S310N NOLL33dSNI 1VNl3 AINO 3Sf1 N0103dSNI bOd 30Vd SIHl S31ON NO1103dSNI SVO HOf1021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK qf. .I irm'U1_ CITY YARMOUTH (WEST) MA DATE 4/1/22 PERMIT #•° — ly. JOBSITE ADDRESS 60 JEFFERSON AVE < OWNER'S NAME ARLENE AULD G OWNER ADDRESS ; SAME TEL ''FAX 508 771 1065 TYPE OR OCCUPANCY TYPE COMMERCIAL' 1 EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW. RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES r NO a. . APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 ,; BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER .... ... __... _ � . FIREPLACE . CF;VvL ATOR FURNACE ,1 Aa2 sum,, ::: �,.'~ x ate- 4.. GENERATOR GRILLE INFRARED HEATER ..... k LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER — .. ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER-. -- 1 x OTHER .. ... ::::.v)V'..N%a.gUaC.V::wvC:waavnv.....wWn,....uww.ati..waYa::roMwCM,awlx5ovnu'AUY.mvmlmvMxalttaWvwvv0.ol(aY.xa.VC.nx.AV,wY .:::.. Aa... ': ::: :.v,SvvxalYrixwuarc.va�'pWwn-" .AY.veiis46..],SM,lua:iV\.•titivu w.nv.:.w'vltii(wt s.s .. ... ... >:.+:wy...w.....":.:<.: .wici S ..S a ..:,.:. .nw;:i........ .u._,...(... .. m. .. .. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Li,s1 NO LI I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY ttx...ttu . BOND 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 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 complianc i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C\ -;"k".. ...4.4.".......,^ PLUMBER-GASFITTER NAME '. STEPHEN WINSLOW LICENSE # 12298 i i SIGNATURE MP i MGF JP JGF LPGI CORPORATION # §3281C ', PARTNERSHIPS#I 3 LLC #1 COMPANY NAME: E.F WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON CIRCLE CITY L. 1SOUTH YARMOUTH 1 STATE L MA ZIP 02664 TEL 508-394 7778 FAX; 508 394 8256 CELL N/A _ . - EMAIL INSPECTIONS@EFWINSLOW COM r The Commonwealth of Massachusetts 4-- Department of Industrial Accidents � T ..=,' 'f. Office of Investigations °I Lafayette City Center .....u— 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): I.k I am a employer with 99 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.E 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]** I 1 ❑ 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#I must also till 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 ce the ins/and penalties of perjury that the information provided above is true and correct. Signature: /Y `` L.. Date: 12/01/2021 g 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 2.0 Building Department 3.1=1 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia