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HomeMy WebLinkAboutBLDP&G-23-000771 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK u, ! CITY YARMOUTH MA DATE 8/15122 PERMIT# BLDP-23-000771 JOBSITE ADDRESS 9 SKYLINE DR OWNER'S NAME AMOROSI PETER C P OWNER ADDRESS AMOROSI MARY E 9 SKYLINE DR 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 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 D 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 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 1Q298 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 ❑ ❑ FEES$ PERMIT H PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ffCITY YARMOUTH MA DATE 8/11/22.......-. PERMIT # -5 . 0 I JOBSITE ADDRESS 9 SKYLINE DRIVE OWNER'S NAME PETER AMOROSI P d____ OWNER ADDRESS ESAME TEL 508-394-9007 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EFM EDUCATIONAL 111 RESIDENTIAL '^ PRINT CLEARLY NEW: [ 1 RENOVATION: 0 REPLACEMENT i._'' PLANS SUBMITTED: YES ] NO FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ‘----_ - _ _ _ ___ _.._�, .� -..� IF CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ' _ DEDICATED GREASE SYSTEM _ i_. ._ - ._ , . . : ,_.. � ._ ` .',d._ DEDICATED GRAY WATER SYSTEM I jI i„ I DEDICATED WATER RECYCLE SYSTEM :I I 1 ( I I ii r �_ { DISHWASHER ii DRINKING FOUNTAIN ui j. -. .�: . -.. .:_ _.... . t- .. _.,� � E _ .._.:m_..� ..� ..._... . .... FOOD DISPOSER 9 FLOOR /AREA DRAIN L. wr W t . _. 1 if INTERCEPTOR (INTERIOR) if ._. ,A KITCHEN SINK _ i I__ LAVATORY 11 I 7 ,_- 1 __7_� - , w_._� � r ..M�f ROOF DRAIN If g' a SHOWER STALL^ ? . 1L_ F4. . _ _. .. SERVICE / MOP SINK IMI I I I I I I I II I 1 I I Inli 1 TOILET : ,[ I 51 I_ ... 3 . e_ _..�. ....d... . . - - URINAL > WASHING MACHINE CONNECTION - °__ , WATER HEATER ALL TYPES WATER PIPING _____ _ IIIMtll.. all Min OTHER i _ , , 111111111111111111111111 k 1 r-I. 1 11 r 11111111111 I 1_ 11 l a INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES i n NO Ej IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 'i OTHER TYPE OF INDEMNITY ; I 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 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 LICENSE # 12298 ' SIGNATURE MP! JP __. CORPORATION !. #13281 C :: PARTNERSHI P# LLC r�#� ___ ______ 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 1 N/A EMAIL INSPECTIONS@EFWINSLOW COM The Commonwealth of Massachusetts Department of Industrial Accidents 9 9 Office of Investigations Lafayette City Center ��, 2 Avenue de Lafayette, Boston,MA 02111-1750 `'M y� 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.❑u 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]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 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: 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 ' e the ins and penalties of perjury that the information provided above is true and correct. Signature: -v....A , Date: 12/01/2021 7' "` 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 2.1=1 Building Department 3D City/Town Clerk 4.❑Licensing Board 5❑Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK T BLDP-23-000771 .� CITY YARMOUTH MA DATE August 15,2022 PERMIT# $ JOBSITE ADDRESS 9 SKYLINE DR OWNER'S NAME AMOROSI PETER C G OWNER ADDRESS AMOROSI MARY E 9 SKYLINE DR WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 I 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER 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-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP© MGF 0 JP 0 JGF 0 LPG' 0 CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections anefwinslow.com S310N M3IA321 NV1d #111N213d $:33d ❑ ❑ 1I1%13d 3Hl Stl S3Ai13S NOI1VOIlddtl SIN! oN saA S310N N01103dSNI 1VNId AINO 3Sl 210103dSNI dOd 39Vd SIHI S310N NO1103dSNI SVO HOI10N MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 8/11/22 PERMIT # C 7-1 l .,>.,.. -,.".___zerw:a,.arw3ssr.•^^,ea.. . . y.... -y ,,,:aysaameu�.. —„-.;,i: JOBSITE ADDRESS 9 SKYLINE DRIVE OWNER'S NAME ` PETER AMOROSI OWNER ADDRESS SAME TEL 508-394-9007 IFAXF ;. TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION; REPLACEMENT: 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 FRYOLA T OR _ 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 I 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 NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 1 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 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 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 compliancomli a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LSTEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP MGF Li JP _ JGF LPGI CORPORATION # 3281C PARTNERSHIP # LLC COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS ILREARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 1 02664 TEL 508-394-7778 FAX 508-394-8256 CELL NSA EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts ii-aDepartment of Industrial Accidents V •`' Office of Investigations (4.1 Lafayette City Center f/ 2 Avenue 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.❑� 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]** 11.0 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#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• the in�s a d penalties of perjury that the information provided above is true and correct. Signature: Y hi 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 2.1=1 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.❑Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia