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Home My WebLink AboutBLDP-23-002571 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK uI' CITY YARMOUTH MA DATE 11/9/22 PERMIT# BLDP-23-002571 JOBSITE ADDRESS 193 WHITES PATH OWNERS NAME MID CAPE RACQUET CLUB INC P OWNER ADDRESS C/O MAJEWSKI ASSOC INC 13200 OAKMONT DR FORT MYERS,FL 33907-8030 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 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 2 INTERCEPTOR(INTERIOR) _ KITCHEN SINK LAVATORY 4 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET , 4 URINAL , 2 WASHING MACHINE CONNECTION WATER HEATER WATER PIPING , OTHER i OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 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 I LICENSE 1Q298 SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑it COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY IS 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 ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK — ' CITY YARMOUTH MA DATE 111 /22 PERMIT # �r JOBSITE ADDRESS 193 WHITES PATH = OWNER'S NAME MID CAPE RACQUET CLUB P . OWNER ADDRESS 1 SAME „ TEL 508-237-3511 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ri RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 11 NOLJ FIXTURES Z FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I CROSS CONNECTION DEVICE OINIMIIIIIIIIIIMMINSISIIIIIINSIMM-MillitINMINIMIIMII DEDICATED SPECIAL WASTE SYSTEM " - ' Illiallilailink_r ,s,1111111.11M11.111M11.111.111111. DEDICATED GAS/OIL/SAND SYSTEM1 - a.< E ii DEDICATED GREASE SYSTEM 1 ' _ §1 DEDICATED GRAY WATER SYSTEM YL-. I DEDICATED WATER RECYCLE SYSTEM DISHWASHER I IIIMIIIFIIMIIIMIIIIIIIMMIIIMIIIIOIMIMIUIIM DRINKING FOUNTAIN . 1 �i� � �� '.-F_.--= ri �7 iiMWE FOOD DISPOSER FLOOR /AREA DRAIN MaillignanialliMOIMIONIIIIMINIMEM1111.1111111. INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY 4 111.1..._.. 4 t ! ROOF DRAIN SHOWER STALL SERVICE / MOP SINK ` " .._- TOILET 4.._... URINAL = _.._ . i WASHING MACHINE CONNECTIONi WATER HEATER ALL TYPES wounamamineastaii-- am ima- anumillitallialliall a WATER PIPING _ = h = I OTHER : . 11111111111111 - r lamtniumariainirmar- ,Ear norniii INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES _'r. NO ..___:_ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I ✓ OTHER TYPE OF INDEMNITY 11a BOND L. 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 El 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 proYisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW .LICENSE # . 12298 SIGNATURE MP j JP E ill CORPORATION# 3281C PARTNERSHIP# LLC # COMPANY NAME I E.F. WINSLOW PLUMBING & HEATING 71 ADDRESS 8 REARDON CIRCLE CITY L.,,,Q,OUTH YARNIOUTH STATE ' MA 11 ZIP 02664 TEL 508 394 7778 FAX i[5O83948256 I CELL 1 N/A ] EMAIL i INSPECTIONS@EFWINSLOW COM A A m m r The Commonwealth of Massachusetts Department of Industrial Accidents 9 to Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 .4 .. 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ 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:01/01/2023 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 ptzins'and penalties of perjury that the information provided above is true and correct. ^\ 12/01/2021 Signature: Y �rDate: 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 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5FJ Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia