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HomeMy WebLinkAboutBLDP&G-23-005594 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 4/7/23 PERMIT# BLDP-23-005594 JOBSITE ADDRESS 19 HORSE POND RD OWNER'S NAME[RGIROPOULOS FAIDON P OWNER ADDRESS ARGIROPOULOS PARASKEVI 19 HORSE POND RD WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES FLOORS—. BSM 1 Z 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 111 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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 perm t 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 1f2298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME [STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE lMA I ZIP 02664 TEL 5083947778 FAX —I CELL 7 EMAIL inspections@efwinslow.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ El --- FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -5 pp,_sajwim;, friri / i 5,_0 0 ss 97 CITY 'YARMOUTH MA DATE ;4/4123 PERMIT JOBSITE ADDRESS 19 HORSEPOND ROAD ,„,..j OWNER'S NAMEIJIM ARGEROPOULAOS pOWNER ADDRESS SAME �u TEL 508 771 7785 "� FAX� ,_ ._. TYPE OR OCCUPANCY TYPE COMMERCIAL ni EDUCATIONAL RESIDENTIAL1 v PRINT _ CLEARLY NEW: ,w,U RENOVATION: LI REPLACEMENT: 1 _ PLANS SUBMITTED: YES NO FIXTURES Z FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB w CROSS CONNECTION DEVICEr----- € DEDICATED SPECIAL WASTE SYSTEM �_�.�.�. . 4........ -- .. . ---ir�....... ,.,-- .-i .�,.�..u__. r � ...... , _., � ; R kR {� ? M� SE g ~s� a : a DEDICATED GAS/OIL/SAND SYSTEM 1Iin' DEDICATED GREASE SYSTEMS ��� _ I. DEDICATED GRAY WATER SYSTEM wE _ . DEDICATED WATER RECYCLE SYSTEM IAN _ w 4 . DISHWASHERI e _. ....:...._ .: ....: ......:. .... _. .: a. ....._:. _._::.� DRINKING FOUNTAIN __ . FOOD DISPOSER 1` `° e FLOOR / AREA DRAIN we..a INTERCEPTOR (INTERIOR) 117_1_-1E__,,T1( ,. _ $ KITCHEN SINK i..mm ._ ._; ;1 .. .. E LAVATORY .: _ . .. :I . ;_.. , � .__,,IL„,_ , � 1111.1 ROOF DRAIN ¢ u . „ u, :�,.-, :��.._ ;::N__. �, � :..� .. �.,.� ..a r..� yr, x, w. SHOWER STALL �_. SERVICE l MOP SINK k , . . ._. fig _ r TOILETr__ r- ' _ _ E F. URINAL �, _ ..,,, f f i WASHING MACHINE CONNECTION I.� ,.... r t ;# WATER HEATER ALL TYPES �s 1lW ,.�.,.. � - .. .. .�. _ _�,:..... ...,.��....�. ..�... .. _w. WATER PIPING I k I as aS w R� OTHER i F¢q F B 1--- 1� f IF � �� 1.11 ... .,:... INSURANCE COVERAGE: I have a current Iiabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE �T3 THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I I IT` I� '�cAMh POLICY yea OTHER C I►'" ► IT i neNNin IP,BILI I Ilw� „ ��E POLL, I I HER TYPE �,r uv�r�rr11�1 i r DUIV.J 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 F..,...,. 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 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 lia with II ertine pro' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW 3 .:�.,. .,. .�w. �„ .. .�WINSLOW,, ... .. ... , �a, :;;..:...�,:...:., .. _„ LICENSE # 12298 SIGNATURE MP JP � CORPORATION # 3281C JPARTNERSHIPLJ#L _ LLC0# V.V.X.V COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH 1STATEFTM--1/4:jZIP 02664I TEL 508 394 7778 FAX I98394-8256 CELL N/A ' EMAIL INSPECTIONS@EFWINSLOW COM The Commonwealth of Massachusetts Department of Industrial Accidents 9 f Office of Investigations yl it- Lafayette City Center �r 2 Avenue de Lafayette, Boston, MA 021I1-1750 w � ww».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 120 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.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ 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:23 COMMONWEALTH AVENUE City/State/Zip: CHESTNUT HILL, MA 02467 Policy#or Self-ins. Lic. #2019A Expiration Date: 01/01/2024 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�nd penalties of perjury that the information provided above is true and correct. ///// 01/01/2023 Signature: Y 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): 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑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 Ys CITY YARMOUTH MA DATE April 07,2023 PERMIT# BLDP-23 005594 JOBSITE ADDRESS 19 HORSE POND RD OWNER'S NAME ARGIROPOULOS FAIDON G OWNER ADDRESS ARGIROPOULOS PARASKEVI 19 HORSE POND RD WEST YARMOUTH MA 02673 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❑ 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,8 REARDON CIR CITY IS YARMOUTH STATE MA ZIP 02664 TEL 5083947778 FAX 1 CELL EMAIL inspections4efwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK• ,_ �- 06- S9k-/ • — CITY r YARMOUTH MA DATE PERMITjft JOBSITE ADDRESS 19 HORSEPOND ROAD OWNER'S NAME JIM ARGEROPOULAOS OWNER ADDRESS SAME JTEL5OB-771-7785 FAX 1 TYPE OR ;...__ PRINT OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: ' v PLANS SUBMITTED: YES NO APPLIANCES Z 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES LI NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 AGENT SIGNATURE OF OWNER OR AGENT 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 ssued for this application will be in cornplianc i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. "}" /0461.4PL" PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP v MGF „,.,W JP JGF g r LPG! CORPORATION � # 3281C PARTNERSHIP ,,,,. # LLC COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY r SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508 i'.. t: a, Si xs ..axx,.a„•.a. ...... .. .... ._._ ....:.:.. ...,_., ._._. ._ ,,..' FAX 508-394-8256 CELL N/A 1EMAIL INSPECTIONS@EFWINSLOW.COM APR 07 2023 DEPARTMENT QUILDING By _ -- The Commonwealth of Massachusetts Department of Industrial Accidents :: Office of Investigations :.I- = 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 Leeibly 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.ii I am a employer with 120 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]** 11.1:]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#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:23 COMMONWEALTH AVENUE City/State/Zip: CHESTNUT HILL,MA 02467 Policy#or Self-ins.Lic.#2019A Expiration Date:01/01/2024 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.15-2 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 er the ins and penalties of perjury that the information provided above is true and correct. F/ / 01/01/2023 Signature: Y -" 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): 1.DBoard of Health 20 Building Department 3D City/Town Clerk 4.0 Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.masc goc di❑