The URL can be used to link to this page

Home My WebLink AboutBLDP&G-21-003119 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT==••= TO PERFORM PLUMBING WORK :rr • CITY _�,(14/ a MA DATE Lj (% 1 ) NI PERMIT# eLb(_2.1_ bU31 I JOBSITE ADDRESS L{ ` ' -; -0, E a__ in/cmv OWNER'S NAM PSI , �� ,)/ iLoci 1 P OWNER ADDRESS � - � t7 �,_. ip ].J & ffA� TE L .. .�► :� _ _6. S6 FAX 130 TYPE OR OCCUPANCY TYPE COMMERCIAL �� —' ' PRINT ( ', EDUCATIONAL ] RESIDENTIAL ( "� CLEARLY NEW: ,1 RENOVATION: E i REPLACEMENT: 5- PLANS SUBMITTED: YES Li NOM FIXTURES Z FLOOR-► BSM 1 2 BATHTUB 3 4 5 6 7 8 9 10 11 12 13 14 iftIMITIMCROSS CONNECTION DEVICE �IM _ _ IIM ; � DEDICATED SPECIAL WASTE SYSTEM 1111.1111111111.11 DEDICATED GAS/OIL/SAND SYSTEM MIMM i DEDICATED GREASE SYSTEM _ � ur 1 �� DEDICATED GRAY WATER SYSTEM IIIAIOII i MI NI DEDICATED WATER RECYCLE SYSTEM r----- 1 -----, - iitairliiiii*MMIN DISHWASHER �; DRINKING FOUNTAIN ; ` '-'' FOOD DISPOSER ( 7( � FLOOR/AREA DRAIN I- �M � � �� INTERCEPTOR (INTERIOR) MIMM M �--; KITCHEN SINK (--- �� all LAVATORY 'T'�'�IM � i�-- ROOF DRAIN MMITIFINIMMMIMIMMEMMIntiminkM SHOWER STALL � --� � ^� ik SERVICE / MOP SINK moiM 1 Wi� �i � - MI TOILET Magaini.ar. , ( si URINAL al WASHING MACHINE CONNECTION WATER HEATER ALL TYPES f M��-- M ��,i WATER PIPING OTHER � .�... ... I�, � �._, _ Nil i{, I have a current liability insurance policy or its substa INSURANCE COVERAGE: ntlal equivalent which meets the requirements of MGL 4142, YES -` NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I— i LIABILITY INSURANCE POLICY p� LLL�...� OTHER TYPE OF INDEMNITY I -- BOND ,. 1 NOV i . OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage require 47Mntrtgi :,--;,71-- ,,TMassachusetts General Laws, and that my signature on this permit application waives this requirement. f the: .~ . r�,� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 7 AGENT E3 \�j I hereby certify that all of the details and information I hst ave submitted or entered regarding this application are tru to theand that all plumbing work and installations performed under the permit issued for this application will be in co li wit r II errtine b proof s oy of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME j STEPHEN WINSLOW r --- n .n r-I LICENSE # 112298 i SIGNATURE S MP, JP CORPORATION _ ' 1PARTNERsHIpD#L qy ----, #I3281C _ ._ jLLC ittL____ . . + 9 COMPANY NAME' U. WINSLOW PLUMBING & HEATING ADDRESSk REARDON � s. CIRCLE CITY I SOUTH YARMOUTH I ---- I ISTATE MA ZIP j02664 I TEL J508-394-7778 FAX I508-394-8256 I CELL NIA I 1 EMAIL INSPECTIONS@EFWINSLOW,C OM Gct3 4 b The Commonwealth of Massachusetts • Department oflndustrialAccidents t:T> ? Office of Investigations raw -per Lafayette City Center 2Avenue 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.RI I am a employer with 90 employees(full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no ?, 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. g_ ❑Non-profit [No workers'comp.insurance required] 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c.152,§1(4),and we have 10.0 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 boxtl must also Ell out the section below showing their workers'compensation policy information. **lf 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 kl. 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.#1909A Expiration Date:01/01/2021 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 ccerr' 7 the tains /and penalties of perjury that the information provided above is true and correct. Signature:�.�/ 'r Date:01/02/2020 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): 11]Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.1:1Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: . ,,,..._._ , r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k` ,_ CITY YARMOUTH MA DATE December 02, 202( PERMIT# BLDP-21-003119 -r:v= JOBSITE ADDRESS 401 STATION AVE OWNER'S NAME PAGE SHANDY B CO-TRS G OWNER ADDRESS P J TSOUROS TRUST 401 STATION AVE SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 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, 7 CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(a�efwinslow.com ❑ • ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE:$ PERMIT# PLAN REVIEW NOTES 'IA DDr,iL%�(' AroAdny J r MASSACHUSETTS UNIFORM APPLICATION- = =,— FOR A PERMIT TO PERFORM GAS FITTING WORK :��;�: CITY ii lw... ._. Va/0r0041. MA DATE 1 I/Z /ZO IPERMIT# BU - 2 I -L) I i g JOBSITE ADDRESS!, 'Q ] 5 ]rj,1`j3y, kvt Sa -,,i4fiw A 1 OWNER'S NAME jem kr 5 d-till 1 G OWNER ADDRESS - 61 �DA - wl 0 J1,1I TELJO . 6 .,D6�6IFAXI TYPE OR U Z3 C C' PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL CLEARLY NEW:i RENOVATION: REPLACEMENT: , t-y/ PLANS SUBMITTED: YES I, NO APPLIANCES -1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER i DRYER I—,_ ----.. FIREPLACE ' ___. 1 9!_ Li FRYOLATOR _ FURNACE GENERATOR _ _. ... GRILLE INFRARED HEATER -_ _ LABORATORY COCKS MAKEUP AIR UNIT OVEN — POOL HEATER ROOM / SPACE HEATER - ROOF TOP UNIT TEST 1 - -- UNIT HEATER UNVENTED ROOM HEATER -- , WATER HEATER OTHER aM.. 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 INDEMNITY D BON V.FYI 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. p CHECK ONE ONLY: OWNER 77 AGENT 1-1 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 com lianc f Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' / p a �rtine provision of the PLUMBER-GASFITTER NAME re-TEP'HEN WINSLOW I LICENSE # 12298 SIGNATURE ,-N (a? MP i 1 MGF JP 0 JGF ED LPG!❑ CORPORATION E✓ #LE81C 1 PARTNERSHIP Litt i LLC .,_i# __ COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING I JADDRESSJ8REARDON CIRCLE 1 ' CITY SOUTH YARMOUTH I STATE(� MA 1 ZIPI 02664 ITEL 508-394-7778 _ _ t iii FAX i 508-394-8256 CELL N/A JEMLRSPECiONS@EFWINSLOW.COM _.i . 1 �r • The Commonwealth of Massachusetts Department of Industrial Accidents 9,__._ ,� =:' Office of Investigations ;; - lj Lafayette City Center (` ` fir =l 2 Avenue de Lafayette,Boston,MA 02111-1750 ,` www mass.gov/dia t=`t=- 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): 1.1] 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. 8. ❑Non-profit [No workers' comp.insurance required] 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.111 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#I. 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.#1909A -Expiration Date:01/01/2021 — 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 i the ins and penalties of pe►jury that the information provided above is true and correct. ' 01/02/2020 g Si nature: . ` Y ."..0/ 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❑Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK `k s T CITY YARMOUTH MA DATE 12/2/20 PERMIT# BLDP-21-003119 . r/ JOBSITE ADDRESS 401 STATION AVE OWNER'S NAME PAGE SHANDY B CO-TRS P OWNER ADDRESS P J TSOUROS TRUST 401 STATION AVE SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW D RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ FIXTURES _I 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 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 D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ 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. PLUMBERS NAME Stephen Winslow LICENSE 12298 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 PERMIT n n FEES$ PERMIT# PLAN REVIEW NOTES