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HomeMy WebLinkAboutBLDP&G-22-003609 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 12/29/21 UPERMIT# BLDP-22-003609 JOBSITE ADDRESS 130 CAPT BLOUNT RD OWNERS NAME Daniel Zona P OWNER ADDRESS 30 CAPT BLOUNT RD SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES El NO❑ FIXTURES 1 FLOORS— l3SM 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 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❑ 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 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 El FEES$ PERMIT# PLAN REVIEW NOTES S . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 4'-= . CITY YARMOUTH SOUTH MA DATE 12/14/21 I PERMIT# JOBSITE ADDRESS 30 CAPTAIN BLUNT ROAD I OWNER'S NAME DANIEL ZONA I P OWNER ADDRESS 47 IRETA ROAD TEL 508-498-6585 IFAX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ❑ RESIDENTIAL El PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES LI NOD FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 r._ 11 ` 111 I 6 . 1 I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM j r j 1 1 I DEDICATED GAS/OIL/SAND SYSTEM , DEDICATED GREASE SYSTEM 1 i DEDICATED GRAY WATER SYSTEM 1 11 1 111 i 1 DEDICATED WATER RECYCLE iiit :iiiiiiiiiit l DISHWASHER DRINKING FOUNTAIN I FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) , u ( h ... , '''��, I� �� ,�. -`I KITCHEN SINK LAVATORY 11111111111 SERVICE/MOP SINK II �iROOF DRAIN SHOWER STALL 1 I TOILET I MEMN Mill NOM M NMI MN NM ME NMIMN MI MI MIR URINAL IMF Mill Miller Mir 1.11111111111111111111111Mill—I Intillell OTHERWASHING MACHINE CONNECTION 1 1 WATER HEATER ALL'TYPES i 11 __ II _.. I ( il r mow _apart; INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO Ej 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. CHECK ONE ONLY: OWNER El 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 a to the t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co li wit II ertine proyisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f/ Y4... ,..,.._._..- PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP ID JP CORPORATION El# 3281C JPARTNERSHIPL# LLC®# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING J ADDRESS 8 REARDON CIRCLE • CITY SOUTH YARMOUTH STATE MA J 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 u _ ► Office of Investigations `ail- Lafayette City Center 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. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.El 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. 0 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]** 11.0 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 ce the insand penalties of perjury that the information provided above is true and correct Signature: Y " 'A/-�" 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.Board of Health 2.11:Building Department 3.❑City/Town Clerk 4.['Licensing 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 CITY YARMOUTH MA DATE December 29,2021 PERMIT# BLDP 22 003609 _ 11 JOBSITE ADDRESS 30 CAPT BLOUNT RD OWNER'S NAME Daniel Zona G OWNER ADDRESS 30 CAPT BLOUNT RD SOUTH YARMOUTH MA 02664 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 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 0 MGF ❑ JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(aietwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES a �. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -:-='l f CITY YARMOUTH SOUTH) ' MA DATE 12/14/21 I PERMIT# JOBSITE ADDRESS T30 CAPTAIN BLUNT ROAD OWNER'S NAME DANIEL ZONA 1 GOWNER ADDRESS 47 IRETA ROAD I TEL 508-498-6585 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL LI PRINT CLEARLY NEW:El RENOVATION:LI REPLACEMENT:Ej PLANS SUBMITTED: YES Li NOEI APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -' E11111[MMO BOOSTER Mi 1 . _ CONVERSION BURNER minis• 1! I o " l 'NEM LW,:n COOK STOVE r 1 _. ' DIRECT VENT HEATER ,` DRYER moor 'I I l FIREPLACE 1111111111111111111111111 FRYOLATOR 11110111,111111 OM IT , FURNACE 9 i, 1f `W._ GENERATOR MI 11.11111111,1111111,1111111111111 MN.OIIIIIIIMIIIIIIMN 111111011.11111*11 GRILLE 11111111111111111111,1.111.111111111111111111_ INIFIIII 'I_ INFRARED HEATER 1111111 M.111111 11111,11111,1 i ,Oil MOM OM Wait-MT Mt LABORATORY COCKSIlj,1,111111 MI Mt Wm am MAKEUP AIR UNIT11.111.1111111111 [ OVENtalli M.1.111111111111111111111111,Wing ,1 POOL HEATER ROOM/SPACE HEATER RuasE ROOF TOP UNIT 111110111'a1I 1 NM NM M M'11111111111111.10101101 TEST ———,—MR 111.0111111 laltiffillallill. WO OM UNIT HEATER 111111111111 M MI `1'� l UNVENTED ROOM HEATER ! I WATER HEATER I , ( OTHER i 1 II, 1 I .�m it .. .T i'allillill OM ilia Mt MI INSURANCE COVERAGE _ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES . NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ,,,J OTHER TYPE INDEMNITY Ejj 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 Li 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 t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian a Pprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE#,12298 SIGNATURE MP MGF LI JP LI JGF 0 LPG(LI CORPORATION EJ#r3281C PARTNERSHIP 0# LC 0# COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS,8 REARDON CIRCLE CITY SOUTH YARMOUTH STATEFM-A-1 ZIP 02664 JTEL 508-394-7778 FAX 508-394-8256 CELL N/A 'EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents :F.=� , — Office of Investigations c:: l= —p — , Lafayette City Center A(r�"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. 0 Restaurant/Bar/Eating Establishment 2.0 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. El Non-profit 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.❑ 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 *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. #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 ce of the ins and penalties of perjury that the information provided above is true and correct. ,F/ 12/01/2021 Signature: r' " -...../0-r- 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.❑City/Town Clerk 4.0Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia