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HomeMy WebLinkAboutBLDP-21-000812 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 10aCITY YARMOUTH MA DATE 8/19/20 PERMIT# BLDP-21-000812 JOBSITE ADDRESS 30 SHORE SIDE DR OWNERS NAME HOWIE DIANE TR P OWNER ADDRESS THE HOWIE CAPE COD RESIDENCE TRUST 16 LITTLE MOUNTAIN ROAD OLD TEL L TAPPAN,NJ 07675-7014 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENTS,0 PLANS SUBMITTED: YES NO FIXTURES T FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND 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 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER TYPE 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'S NAME Stephen Winslow LICENSE 1Q298 SIGNATURE MP 0 JP 0 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 ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ''''illi ii ti , __ i.. CITY V MA DATE PERMIT # 0 I C)Oi JOBSITE ADDRESS 1 50 51l0[f$ Vk I(, SOJIt'i,1 I„fMOj/ 4, OWNER'S NAME Dennis _//Ovt') C J p OWNER ADDRESS • . .. j TEL[. f):$3 ` 15.0 , JFAX[ j TYPE OR OCCUPANCY TYPE COMMERCIAL Ill] EDUCATIONAL 0 RESIDENTIAL L PRINT _ CLEARLY NEW: El] RENOVATION: [ I REPLACEMENT: [_1 PLANS SUBMITTED: YES [j NO fl FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB - _.—._ -- •r-- - -- --- i------, -- �. .F- -�- I ---_ 'I -_------- __I_ s 1------ ,i__w--;1- -,r -----, CROSS CONNECTION DEVICE --- ------ - - - - -:- -----.1---------- ___ _-- DEDICATED SPECIAL WASTE SYSTEM !-_-- --- 1_. —_11--1 I :.1 - -_ - ,L_ i- ---, _ _ _1-----._`i—__.- 1__ _ _ �_______ DEDICATED GAS/OIUSANDSYSTEM , 1) ,i+ :i .1 =1--_._...._,1 , 11_.._..-_'I. -._ --- i— ,i--_fi- _�[___-_ 1 __-__1-- --- DEDICATED GREASE SYSTEM `1- [--- 'F --- __ ------I —,I- -1---1- :i-----. DEDICATED GRAY WATER SYSTEM IT 71E71 _I ) - DEDICATED WATER RECYCLE SYSTEM 1 - I 1---- r .:. ._.�Ir- -1-_-1 _ -:1—�.!`_-��' r- - l___ ___- DISHWASHER I --- -1- I------ i tl I�---- - 1---_1 .:.... ..1. .-� - ----- -- -- DRINKING FOUNTAIN 1 --- r--:-,I_-._._-. I1. i II _ !I .. i FOOD DISPOSER .,_-„..1--- _.- -: ----4----- IT- FLOOR/AREA DRAIN I_ I 7'_ -- TI - __. . __71 __- F7-- ._. INTERCEPTOR (INTERIOR) I !I . . ..-1; 11. t I. � .I . .: _ . 11K. . � l _ 'i ;I . I I I_ _ KITCHEN SINK !_ 11 .1 ,..._11_,,_,. ' IL.______. ii.�.r:_ x IL _ _. ±_ _fit --- I _� .- r_ _iU-- {1 1--- LAVATORY I. —r_ 1 `1 �JL L_ L_.- - I +L_ _ . �� IF 1 . - ,i ^- -- ROOF DRAIN r- SHOWER STALL ;--- 1 s i--- -,[--,1----I I t (-� ---'1 SERVICE / MOP SINK _ ._11....__-__fl i� . 'r..i� y_1r.._. _.E1.1i (7, 1.. _ _, i Ih n 1 j , TOILET ,7 11 if---;• --- ( # 1�`i- I-----7 -71- --,i-- - -- 1-----. URINAL I_ ,�----- I-----7 ----__. 1 [- l r , ;I---- I .- 11-.. . _.I I_ . .. -I!_ ,[.._ L WASHING MACHINE CONNECTION j ; _ ___ 1_ 1 _ 'I _ i _ _ ,, ;�w1- 1 I I _ WATER HEATER ALL TYPES 1- -'[ 1 I i ]i 11 Iw i 1. F n__ ,I 1 _ i I WATER PIPING -__ I— I—. F— i -T I[-----_-{I- I - I '1 .jr------ { . . _ .- - OTHER 1 7---- -- . -- 1 , -- ,i ;1 = - _ - : 71 r-------- I E __ ms. ! ._ _'_ i� I ^1 - l— INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [' 1 NO I_ J IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 1 LIABILITY INSURANCE POLICY 171 OTHER TYPE OF INDEMNITY I --I BOND I-"H 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 I-1 AGENT I-I 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 st of my knowledge and that all plumbing work 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 WINSLOW81 �___—_____ _ ___ ILICENSE # 122-- 9 SIGNATURE MPH JP _-i CORPORATION i ]#11281C PARTNERSHIPL_ #j 11 LLC[—# ______I- y COMPANY NAME I E.F. WINSLOW PLUMBING & HEATING -1 ADDRESS 18 REARDON CIRCLE -w_ - i CITY l SOUTH YARMOUTH J STATE r-MA i ZIP 1 02664 ( TEL I 508-394-7778 FAX 1508-394-8256 CELL NIA 1 EMAIL [iLSPECTIONS@EFWINSLOW.COM ____] IA 6/6 The Commonwealth of Massachusetts Department of Industrial Accidents I) _ Office of Investigations :A l Lafayette City Center .=a — 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 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. [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 *My 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. #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 imprisomnent, 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: 'i l/..•�'l'....'-- 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): 1.1=1Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia