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HomeMy WebLinkAboutBLDP-21-002655 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w c CITY YARMOUTH MA DATE 11/10/20 PERMIT# BLDP-21-002655 JOBSITE ADDRESS 42 DEBS HILL RD UNIT 3A OWNER'S NAME CAMPANE ROSEMARY ANN P OWNER ADDRESS 42 DEBS HILL RD YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURES z 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE _DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SIN_K 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 LICENSEIL298 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 El FEES$ PERMIT# PLAN REVIEW NOTES --V -,g:1,. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK lrmi- & =_ur_I s CITY YARMOUTH I MA DATE 10/27/20. PERMIT#I 12'7i1��7(OS-S JOBSITE ADDRESS 42 DEBS HILL ROAD,YARMOUTHPORT OWNER'S NAME CAMPANE POWNER ADDRESS TEL 508.394.4065 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL LI EDUCATIONAL LI RESIDENTIAL LJ PRINT CLEARLY NEW:El RENOVATION:0 REPLACEMENT:Q PLANS SUBMITTED: YES® NOEl FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB II CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEMvim DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I DISHWASHER DRINKING FOUNTAIN � �•,�, _, �_ - li [ ,. jsa_ re _ W ,,-II . Z4A I FOOD DISPOSER �_ . ,1I_.__ [ FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINKLAVATORY �• • RRRRRRRRRNRRR ••s TOILETSHOWER STALL Ming_WWWWW111111=111111111rUIPO WM SERVICE/MOP SINK [ 11 [ nil I II IiI : , WASHING MACHINE CONNECTION WATER HEATER ALL TYPES OMB MEI 111111 MINI IMO 1111111111 MINI ISM MI nil NM MIR IIIIIII MI5 MINI WATER PIPING OTHER w._.__._... ._. .�� I C. f i A 9*A ' ., W/O 539088$40.00 )•r 1 ..--. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGIL Ch.142, YES 0 NO a IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOV LIABILITY INSURANCE POLICY 0 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. CHECK ONE ONLY: OWNER ® AGENT Ej 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 a 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 Ii wit II ertine proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP[ JP El CORPORATIONS# 3281C PARTNERSHIP®# ILLCLI# 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 � ►� l Office of Investigations ' —" 1' Lafayette City Center T. I /%tit2 Avenue de Lafayette, Boston,MA 02111-1750 ,:,4 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. 0 Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7• 0 Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-proftt 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. #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 ce 7 the ins and penalties of perjury that the information provided above is true and correct. Signature: Y "` .w 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): 1IBoard of Health 2.❑Building Department 3.1=I City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia