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HomeMy WebLinkAboutBLDP&G-22-002860 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 11/17/21 PERMIT# BLDP-22-002860 JOBSITE ADDRESS 2 IDLEWOOD DR OWNER'S NAME WITMAN BRIAN K TRS P OWNER ADDRESS WITMAN BARBARA A TRS 2 IDLEWOOD DR SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTIIRFS 1 FLOORS— RSM 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❑ 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❑ 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 LICENSEI1Q298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH 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 El El FEES$ PERMIT# PLAN REVIEW NOTES . r. . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - IS—1-=". 5 CITY [YARMOUTH (SOUTH) 1 MA DATE 11/15/2021 PERMIT # - -" JC)BSITE ADDRESS 12 IDLEWOOD DR., S. YARMOUTH, MA 0266441 OWNER'S NAME BARBARA WITMAN P , OWNER ADDRESS SAME — ...,i ._„,,__ „_ _ „ _ ,,,_,___:_._.___J TEL 4135313567 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Li RESIDENTIAL J PRINT CLEARLY NEW: RENOVATION REPLACEMENT: LI PLANS SUBMITTED: YES Ej N01 FIXTURES Z FLOOR—I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB W w�.�,..._._ 'rill. _ . CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM 1 Uj :..w. v DEDICATED GAS/OIL/SAND SYSTEM in ir_iiiya LuaojllIlli DEDICATED GREASE_ SYSTEM �4 ..... _ ,..� DEDICATED GRAY 1NATER SYSTEM DEDICATED WATER RECYCLE SYSTEM / DISHWASHER E _ �� . .� � r DRINKING FOUNTAIN �� : ISM1 ._u MI L r FOOD DISPOSER _ FLOOR /AREA DRAIN 'E FMB' al IIMMIIMI INTERCEPTOR (INTERIOR) I _ £:F KITCHEN SINK I I !� F- LAVATORY In ROOF DRAIN , _ SHOWER STALL ,_ M� _. , I` 1 SERVICE / MOP SINK tF 11 TOILET I., , 1 t Ili11 URINAL al NMI OM 111111 Ma MI — MI NS MN MIN MINN WASHING MACHINE CONNECTION IIIMIIIIIIIIIMIIIIIIIIIIIIIIIIMIOIIIIIIIIIIIIIIIIIIIIIBJIIIMIIIIIIMIIIIINIIIII ... _11 IIIII WATER HEATER ALL TYPES 1 1 _ ` WATER PIPING I I. . R _ I_ at r— am OTHER 11111111111111 O 1 I . INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES r:;a NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v OTHER TYPE OF INDEMNITY BOND Ej 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 ' a AGENT l 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 lia with II ertine proYisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �. _4 ...o .."..-- PLUMBER'S NAME I STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP' v JP I CORPORATION ,# 3281CPARTNERSHIP _ 1# LLCf# COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE j CITY[SOUTH YARMOUTH 1 STATE MA ZIP 02664 ........_i TEL 508-394-7778 FAX 508-394-8256 CELL [N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts — Department of Industrial Accidents vJ �" ���'� Office of Investigations 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 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. El 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]** 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 *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 iviGL 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: 7' "` 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): 1I:Board of Health 2.0 Building Department 3.❑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 xS CITY YARMOUTH MA DATE November 17,202'PERMIT BLDP-22-002860 c... JOBSITE ADDRESS 2 IDLEWOOD DR OWNER'S NAME WITMAN BRIAN K TRS G OWNER ADDRESS WITMAN BARBARA A TRS 2 IDLEWOOD DR SOUTH YARMOUTH MA 02664 TEL __ TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© 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 El BOND ❑ 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-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP©MGF 0 JP❑ JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 _ TEL FAX CELL EMAIL inspectionstSaefwinslow.com • S3lON MlIAal NV1d #LIV d ❑ ❑ lMW2l3d 3Hl SV SAS NOIlVOIIddV 8I1-11 ON SBA S310N NOI103dSNI 1VNid AlN0 3Sf1):10103dSNI NO3 39Vd SIHl S310N NOI103dSNI SVO H9f102i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK q'5- "rmia.:1117. -- s CITY YARMOUTH (SOUTH) _ �p e �a.. .� ... MA DATE 11/15/2021 1 PERMIT # 2Z Z JOBSITE ADDRESS 2 IDLEWOOD DR, S. YARMOUTH, MA 02664 OWNER'S NAME BARBARA WITMAN j GOWNER ADDRESS '`SAME 1TEL4135313567 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ! EDUCATIONAL RESIDENTIAL PRINT CLEARLY _,,..` NEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES NO r APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i K I . 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 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER , WATER HEATER _._ OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1 v NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v OTHER TYPE 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 1 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. 0 ? ' .....ol....�r PLUMBER-GASFITTER NAME ! STEPHEN WINSLOW LICENSE #I 12298 1 SIGNATURE MP v MGF JP JGF LPGI CORPORATION : # 3281 C PARTNERSHIP # L ]LLC # COMPANY NAME E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP!. IPl 02664 TEL 508-394-7778 FAX 1508-394-8256 CELL NIA 1EMAlLNSPECTIONS@EFWINSLOW COM The Commonwealth of Massachusetts + Department of Industrial Accidents --gb Office of Investigations (1 `"\ 11.);) Lafayette City Center 1 2Avenue de Lafayette, Boston, MA 02111-1750 . m_ 1zwww.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]** 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 *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 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): 1.1Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia