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HomeMy WebLinkAboutBLDP&G-23-000680 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 8/9122 PERMIT# BLDP-23-000680 JOBSITE ADDRESS 42&44 WILFIN RD OWNER'S NAME MESSURI MARY P OWNER ADDRESS 34 COOLIDGE RD WINCHESTER,MA 01890-2251 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL m PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ NO❑ FIXTURES -I FLOORS-s 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❑ 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 LICENSE 16298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 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 FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - �s,mm _ __..._. ,..... ... ._ � � CITY SOUTH YARMOUTH _ `y I MA DATE [ 8/3/22 1 PERMIT # �--s y COL;S JOBSITE ADDRESS 142 & 44 WILFIN ROAD OWNER'S NAME LILLIAN ELY _ ___ OWNER ADDRESS SAME TEL „413-478-1019 FAX _ ____. . _.._,...' TYPE OR OCCUPANCY TYPE COMMERCIAL __ EDUCATIONAL ;1 RESIDENTIAL ril PRINT CLEARLY NEW: 1 I RENOVATION: ID REPLACEMENT: ` i ..I PLANS SUBMITTED: YES Ell NO1 FIXTURES Z FLOOR--► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 11 - 1 CROSS CONNECTION DEVICE � r��, , � „ : DEDICATED SPECIAL_ WASTE SYSTEM I 1 Ti 1 1r DEDICATED GAS/OIL/SAND SYSTEM €I 1 ir i --I - _ , DEDICATED GREASE SYSTEM 1 1� —q1 L if DEDICATED GRAY WATER SYSTEM ,� DEDICATED WATER RECYCLE SYSTEM °_ I i DISHWASHER I I _ ii, tt.. . €`. Ti DRINKING FOUNTAIN ._, _ �.. �.. FOOD DISPOSER 1 1E .1 ; _ FLOOR /AREA DRAIN I - L 1$ F (INTERIOR) � I - ...... . :e ,, INTERCEPTOR INTEI�IOR 1 I . _ . €� __. ¢_._ _1 x�� �' 1 .._ KITCHEN SINK 3 I. LAVATORY ' __ __ adi d F It ROOF DRAIN __ _; _ -'1-- _� __W __. I +3 . ' I II I!_ SHOWER STALL �.-' . ____# Mill SERVICE / MOP SINK 1 1_. _ 1 .__ 1 _ TOILET I _.,.. ._ ._ _. l -: I � � , URINAL 1_:..: P ` 1 NIP 1111 NM I 1 OW ,_ :. ... ... WASHING MACHINE CONNECTION ::_ Inn MN UM .. WATER HEATER ALL TYPES r 1 1 IIIIIIIIIIIIIIIIIIIIIIIIIIIIKIMIIIIIIIIIIIIIIIIIIIIIIIIIIIINIIIIIIMIIJIIIIIIIHIIIIIF IWATER PIPING l OTHER : I 111 gg t IL _ limma,,H_ _ _ , 1l INSURANCE COVERAGE: I have a current liabilit&insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 7 NO n._,_ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE OF INDEMNITY BOND E„ 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 e to the b t of my knowledge and that all plumbing wcrk 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 ' S_' EPHEN WINSLOW 1 LICENSE # ' 12298 SIGNATURE MP i. JP L) CORPORATION # 3281C PARTNERSHIPII# I LLC__. # COMPANY NAME E.F. WINSLOW PLUMBING & HEATING JADDRESS8REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A Il EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts 9 Department of Industrial Accidents ,` -, ,2 Office of Investigations ;� Lafayette City Center N / 2 Avenue de Lafayette, Boston,MA 02111-1750 c =� 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 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]** 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 Investigation., of the DIA for insurance coverage verification. I do hereby cer ' f the and penalties of perjury that the information provided above is true and correct. 12/01/2021 Signature: Y "` ,^-.1'— 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): 1.11Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.❑Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY IYARMOUTH MA DATE "August09,2022 IPERMIT# BLDP-23-000680 JOBSITE ADDRESS 142&44 WILFIN RD I OWNER'S NAME IMESSURI MARY G OWNER ADDRESS 34 COOLIDGE RD WINCHESTER MA 01890-2251 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT PLANS SUBMITTED:YES❑ NO 0 CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER OF INDEMNITY❑ BOND 0 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 I LICENSE# 12298 SIGNATURE MP©MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: 'STEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH I STATE MA ZIP 026641207 TEL FAX CELL EMAIL IinspectionsWWerwinslow.com S310N M3IA32i Mdlld #lJW2i3d $ :33d ❑ ❑ 1IV 3d 3H1 SV S3/183S NOILVOIlddd SIHl ON sex S310N N01133dSNl 1VNId A1NO 3Sfl 10103dSNl 21bd 3OVd SIHl S310N N01103dSNI SVD Fiona' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ": �.L CITY SOUTH YARMOUTH MA DATE 8/3122 PERMIT # ? I — c)( S c; f JDBSITE ADDRESS 42 & 44 WILFIN ROAD OWNERS NAME LILLIAN ELY G _ OWNER ADDRESS SAME TEL 413-478-1019 FAxr ,., „ „ „ _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES NO APPLIANCES -1 FLOORS-4 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 w MAKEUP AIR UNIT U OVEN POOL HEATER ROOM 1 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 i . NO Li I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY BOND I, m 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 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 a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 0 --. ........./.., PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 . SIGNATURE •^:. .:%o*b'�:$0';biWik'4-1SKY.x( .."h`��'^10Y;:: -::' MP i MGF LA" JP 71 JGF LPGI CORPORATION = i # 13281 C PARTNERSHIP : #E LLC #fi � COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS'8 REARDON CIRCLE CITY ° SOUTH YARMOUTH STATE ` MA ZIP 02664 TEL 508-394-7778 .,_ FAX ' 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents taw �� Office of Investigations ill Lafayette City Center � 2Avenue de Lafayette, Boston,MA 02111-1750 `'~c s` 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]** 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 gliins and penalties of perjury that the information provided above is true and correct. / 12/01/2021 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 f Board of Health 2.1=1 Building Department 30 City/Town Clerk 4.❑Licensing Board 5,0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia