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HomeMy WebLinkAboutBLDP&G-23-004939 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK A r CITY YARMOUTH -I MA DATE 3/8/23 PERMIT# BLDP-23-004939 �� ,r JOBSITE ADDRESS 136 SEAVIEW AVE OWNER'S NAME HOFFMAN CHRISTINE M(LIFE EST) P OWNER ADDRESS 131 SEAVIEW AVE SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0 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 ❑ IF YOU CHECKED YES,PL EASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY❑ BOND El 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 tie 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 Stag Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Stephen Winslow LICENSE98 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ACDRESS 18 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 TEL 5083947778 FAX CELL -1 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 r s-7. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ..,w_.; . tyn) p-_ 73 - ay 9 3 r % =�� CITY ( YARMOUTH ' MA DATE 2/28/23 PERIVTIT JOBSITE ADDRESS 136 SEAVIEW AVENUE I OWNER'S NAME CHRISTINE HOFFMAN OWNER ADDRESS SAME _ TEL 508-375-5743 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL i RESIDENTIAL i„t PRINT CLEARLY NEW: i RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 1 NOL'-t FIXTURES -1 FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB lI 4 1 .._ ___ ,i_____ ' _______L__ —,—...a ,......L.„ —,f , i_......,—,--„' CROSS CONNECTICN DEVICE _ �. �i f DEDICATED SPECIA_ WASTE SYSTEM I° DEDICATED GAS/OIL_/SAND SYSTEM .__ I I I I DEDICATED GREASE SYSTEM I I . I_ .. .._... .' l.. __ L. DEDICATED GRAY WATER SYSTEM _ . .l _._ I.- F DEDICATED WATER RECYCLE SYSTE 1-----Ir--- II - --: �i I ,j _. _ ____ I _,, , DISHWASHER _ """`__ III - `I ---- _ _tt r DRINKING FOUNti crs 12 1 €I II [ .._ I FOOD DISPOSER x f i ___ 'I i — _ _.e FLOOR /AREA D , .. a -__.. 1 i INTERCEPTOR (I © ��•R) .� _.. ._:.. KITCHEN SINK I 3 IEI)_____e- �.._° r .” . 1, aiNil -, - LAVATORY ! I' ' 1r I ii� _ r ROOF DRAIN .£ ` C l - i� � r.. . I - SHOWER STALL t r-- . .�.,.� i C.. 1 SERVICE / MOP S NI._.. - I . - _ _ TOILETum _ URINAL - m1--WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 , �� ;f- WATER PIPING 1 -�--� --------- it _._ OTHER ,1 - ( �� �, I I L i �T 1 , rN._ '+.Y' I - . ... 1 .._.. r — _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ' i j NO _1 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 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 complia with II ertine pro'isio of the Massachusetts State F'Iumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ' STEPHEN WINSLOW _,_____ LICENSE # [ 12298 I SIGNATURE MP i JP CORPORATION [2:#[3281C— 1PARTNERSHIP # I LLC _, #I COMPANY NAME E.F. WINSLOW PLUMBING & HEATING i ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA i ZIP 102664 TEL 508-394-7778 FAX 508-394-8256 CELL 1N/A ' EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 61: is Lafayette City Center R / 2 Avenue de Lafayette, Boston,MA 02111-1750 y /:/ M=i'=-, =� 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): 1.111 I am a employer with 120 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership d have no 7. ❑ Office and/or Sales(incl. real estate, auto,etc.) employees working for me in any c 'ty. [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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.111 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **►f 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:23 COMMONWEALTH AVENUE City/State/Zip: CHESTNUT HILL, MA 02467 Policy#or Self-ins. Lic. #2019A Expiration Date:01/01/2024 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 ^inls and penalties of perjury that the information provided above is true and correct. Signature: Y Date: 01/01/2023 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): 1.111Board of Health 2.❑Building Department 30 City/Town Clerk 4.111Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CM—S TA , CITY YARMOUTH MA DATE 2/28/23 PERMIT# ti JOBSITE ADDRESS 136 SEAVIEW AVENUE OWNER'S NAME CHRISTINE HOFFMAN OWNER ADDRESS SAME TEL 508-375-5743 FAX 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 HEALEB-. — DRYER t— FIREPLACEs1 r —+�w FRYOLATOR „ FURNACE GENERATOR ""t o0 GRILLE 0 INFRARED HEAT I ) z LABORATORY C MAKEUP AIR UNI �5 OVEN m POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM I-EATER WATER HEATER 1 OTHER INSURANCE COVERAGE I have a current Iiabili 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 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 o"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 i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r ...p. PLUMBER-GASFITTEF NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP / MGF JP JGF LPGI CORPORATION # 3281C PARTNERSHIP # LLC # 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 tt Office of Investigations 4 Lafayette City Center t,,...,,,_ ---,, 2 Avenue de Lafayette, Boston,MA 02111-1750 -ems='- 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 120 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]** 11.111 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. 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:23 COMMONWEALTH AVENUE City/State/Zip: CHESTNUT HILL, MA 02467 Policy#or Self-ins. Lic. #2019A Expiration Date: 01/01/2024 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 perjury that the information provided above is true and correct. ' 01/01/2023 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): 1.1=IBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia