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Home My WebLink AboutBLDP-21-006134 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK a. CITY YARMOUTH ] MA DATE 4/23/21 PERMIT# BLDP-21-006134 JOBSITE ADDRESS 14 JARED LN OWNER'S NAME AMEER JOHN PIERRE P OWNER ADDRESS PEREZ MARGARITA 14 JARED LN YARMOUTH PORT,MA 02675-2062 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES - =LOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASES 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 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❑ 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. PLUMBERS NAME Stephen Winslow LICENSE 1 Q298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# • COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA 7 ZIP 026641207 TEL FAX CELL -I EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ FEESS PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK re'irr= attr : CITY �� +.. .a! �" MA DATE 1�.,,Ij 6.r.r.,Z I ; PERMIT# ry JOBSITE ADDRESS l iLli. e C _ .... /i?i1(?v1-47E0/f'-- OWNER'S NAME ....._. Qh.+'t_.��../�M1�E'/ ..__..._.__..._.........,._�.._.W_ OWNER ADDRESS I TEL VG '1 3 ) d _ FAX L y j TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL Er PRINT CLEARLY NEW: _.! RENOVATION: (r,. REPLACEMENT: Si PLANS SUBMITTED: YES �. NOD FIXTURES 1 FLOOR—; BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB � � _ •.>• - R-i aT=srrv.� �sy�� r:�_�t i� a _=cr•__.,- _'--__.:rr.__ __-T.-. '�•_ -7=N -`•__.. CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM _..._ _.. _ .-_,... __ .: : � ; - --- ,...-..._.._. . G.... . . [. DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM ' - ‘1,-1117 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _._[ 'f t� L.i. _ [_..��_.�. _ _ DISHWASHER - -1' -- r_1_7177- - DRINKING FOUNTAIN FOOD DISPOSER 1 - °[- = �I . � ,P I'�TT�'�L� FLOOR/AREA DRAIN _ INTERCEPTOR (INTERIOR) � �� -L z , - - _ _ .- KITCHEN SINK LAVATORY • ROOF DRAIN `-:_:-- = : ._ _ _ :- _-TTThM __ _ _.,.._.__..; -.: SHOWER STALL [_: _ __:' I _. ___ _. ___ _: �_ _ . 1. __ -- _:.: __ _- � SERVICE / MOP SINK TOILET ; URINAL -'l . _ WASHING MACHINE CONNECTION _ f _ ' WATER HEATER ALL TYPES ---- 1 -:--- ----_l - - ;:._ I' WATER PIPING ;1 :..� - -:� --- 1 _. _- :- -- OTHER - - _ Mit-- -6:T=,/:c:=.�:,=r��:::,'-�;�...�:�—rr�.s».-.,,�.:v.:._.-:_-.�„-�--� �-�. '---- ��=�-.r-T.�J�-._-�_—`�.-r__�'L;._.�=,:vim�'::.a�.sT.•��---.�� J 1.1...111-1111101101111 _ :IMO* INSURANCE COVERAGE: I have a current liabilit ,insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO ri IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY �✓1 OTHER TYPE OF INDEMNITY U 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 1J AGENT L SIGNATURE OF OWNER OR AGENT iv, 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 Ii with li ertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME [ STEPHEN WINSLOW - —I LICENSE # 12298 SIGNATURE MP I JPL .i CORPORATION Li# 3281C PARTNERSHIP)#I-_---__-_----____ COMPANY NAME ES'. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 5.08-394-7778 FAX r508-394-82561 CELL IN/Al EMAIL INSPECTIONS@EFWINSLOW.COM • - — 1 The Commonwealth.of Massachusetts Department of Industrial Accidents r Office of Investigations Lafayette City Center 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. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ 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]** 11.11Health 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#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• -un the insa and penalties of perjury that the information provided above is true and correct. Signature: 7' �-' 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..OBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.OLicensing Board 5.0 Selectmen's Office 6.[]Other Contact Person: Phone#: www.mass.gov/dia