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HomeMy WebLinkAboutBLDP-23-000043 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA. DATE 7/5/22 PERMIT# BLDP-23-000043 JOBSITE ADDRESS 12 WAGTAIL LN OWNERS NAME DESKA RICHARD J P OWNER ADDRESS DESKA CATHERINE A 37 MONROE ST CHICOPEE,MA 01020 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT El PLANS SUBMITTED: YES NO El 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 1 WATER HEATER 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 El 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 fe298 SIGNATURE MP ©i JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME 'STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 1026641207 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 0 0 FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 3Imt; CITY !YARMOUTH WEST z MA DATE €6/30/22 PERMIT # 2 `_,6 / 4%,. Warn,, =+.sx,+.-n<,10,.m,,—zM.V.,,JAx gym: .. ate,v Rrow, JDBSITE ADDRESS '12 WAGTAIL LN, W YARMOUTH, MA 02673 OWNER'S NAME CATHERINE DESKA POWNER ADDRESS 37 1MONR0EST, CHICOPEE, MA 01020 1 TELL 413)519-5159 FAX I-J- - t TYPE OR CCCUPANCY TYPE COMMERCIAL '_ EDUCATIONAL ii RESIDENTIAL ; PRINT � L CLEARLY NEW: b RENOVATION: REPLACEMENT: �� PLANS SUBMITTED: YES El NO FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB -IL _... _. ET� IIII. MI 1 CROSS CONNECTION DEVICE .. . _ DEDICATED SPECIAL WASTE SYSTEM I ' DEDICATED GAS/OIL/SAND SYSTEM I 1 on �.. 3 DEDICATED GREASE SYSTEM = I, aillim DEDICATED GRAY WATER SYSTEM IaIi �minim um DEDICATED WATER RECYCLE SYSTEM I '----11- _. '. _.__ �� - DISHWASHER ' Ii initinimi DRINKING FOUNTAIN MI .__..: .._. I I 1111111111111111111111,111111 FOOD DISPOSER IN NI NM 1111111MIIIMIIIIII 1L I II I FLOOR 1 AREA DRAIN I .w onramormitslimmanoniamm.. INTERCEPTOR (INTERIOR) KITCHEN SINK .,f it 1 _ Ei... _ . LAVATORY ... .___ .... �EN ` I .. ' 1111 ism ROOF DRAIN NM I SHOWER STALL :.. _. MOM i_ _ d I NEI SERVICE l MOP SINK( 'I1111111111.111111111111En TOILET I IIt is . 1 URINAL .., � s � ' � :, ..�. .� " i' __ I I WASHING MACHINE CONNECTION I.:M . . .w� A ._. _... If WATER HEATER ALl_ TYPES l WATER PIPING i illiallinnillill MIIi OTHER _.. I Es aimum, .. ,.....____,____ ....__ , ! .111115 NM 111111113111111 NU INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ------ ---- LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY x 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 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 Nork and installations performed under the permit issued for this application will be in corn lia with II ertine pro' isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP1v JP D CORPORATION # 3281C ............ PARTNERSHIP L# lU ; # .. ., COMPANY NAME € E.F. WINSLOW PLUMBING & HEATING i ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE E MA ZIP 02664 TEL 508-394-7778 , FAX [ 94-8256 ] CELL N/A EMAIL [ CONS@EFWINSLOW.COM . , re'-R The Commonwealth of Massachusetts ' Department of Industrial Accidents P \ ,fiA Office of Investigations P1- Lafayette City Center -�'�fq 2 Avenue de Lafayette, Boston, MA 02111-1750 M =/>/ 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.❑ Health Care 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: 01/01/2023 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 cer the ins/and penalties of perjury that the information provided above is true and correct. Signature: 7' -��/^ 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): 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther j Contact Person: Phone#: www.mass.gov/dia