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HomeMy WebLinkAboutBLDP&G-21-004682 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 2/18121 PERMIT# BLDP-21-004682 ' JOBSITE ADDRESS 47 DRIVING TEE CIR OWNER'S NAME MURPHY MARGARIET B P OWNER ADDRESS MURPHY BRIAN D 47 DRIVING TEE CIRCLE SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: 0 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/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 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,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 f2298 SIGNATURE MP © 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 st 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 _,ani p F _ n— LDP -Z( -00 1'2- - T:_Ui s CITY YARMOUTH 1 MA DATE 02/12/21 PERMIT# d JOBSITE ADDRESS 47 DRIVING TEE CIRCLE OWNER'S NAME MURPHY,BRIAN P OWNER ADDRESS SOUTH YARMOUTH TEL 2037333568 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ID EDUCATIONAL Li RESIDENTIAL ID PRINT CLEARLY NEW:Li RENOVATION:Li REPLACEMENT:[ PLANS SUBMITTED: YES® N0Li FIXTURES-1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I, � '.__ i CROSS CONNECTION DEVICE �. DEDICATED SPECIAL WASTE SYSTEM 1 I �, '+ DEDICATED GAS/OIUSAND SYSTEM 1 1 1 1 I I 1 I I I II I ;I DEDICATED GREASE SYSTEM MN MO iiiii iiiii MI I®MN 1111 MN MN XII NM MI NMI MI DEDICATED GRAY WATER SYSTEM lI H it ( ? i___ I DEDICATED WATER RECYCLE SYSTEM !, 1�ll 'I _ i I , DISHWASHER N In 1001 , __. ._ .. .. DRINKING FOUNTAIN I 1 FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) ' liiiii 1 . 1 . . . KITCHEN SINK LAVATORY MI .iinnimmin 1 Run ROOF DRAIN Wi I1 SHOWER STALL 1111111111111111111111111111111111111111111ff MUM 1111111111111111111111111111111111111111 SERVICE/MOP SINK PINE _ ( �� i i TOILET Mi.111011111 OM In.NM MI MO EMI ME MI 1111 OM 11111 NMI URINAL WASHING MACHINE CONNECTION 9O , WATER HEATER ALL TYPES 1 I I FWATER — ._ G '� � .I � OTHER PIPING � I I I r i I 1 W/O 545024 .40.00 afll '�i1111111Ii :11111111 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[jJ NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Li OTHER TYPE OF INDEMNITY Li 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 0 AGENT ED 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 li 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 CORPORATION0# 3281C PARTNERSHIP # LLCE# 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 r+j � 1. Office of Investigations 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): 1.111 I am a employer with 90 employees (full and/ 5. U 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.❑ 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#l. 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:01/01/2022 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 • ll�the ins and penalties of perjury that the information provided above is true and correct. Signature: Y Date: 01/02/2021 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 2.0 Building Department 3.0 City/Town Clerk 4.1:Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK NW. CITY IYARMOUTH MA DATE 02/12/21 PERMIT# `9-Z -«'� �'L JOBSITE ADDRESS 47 DRIVING TEE CIRCLE _OWNER'S NAME MURPHY,BRIAN GOWNER ADDRESS SOUTH YARMOUTH TEL 2037333568 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL Lj RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:Li REPLACEMENT:a.J PLANS SUBMITTED: YES__I NO APPLIANCES 1 FLOORS-) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER NM ', ' �` . r ` OM ro� BOOSTER i I i a & I '-- aio maw'mom. CONVERSION BURNER COOK STOVE ... . . ._ W... _ .. DIRECT VENT HEATER 1.11 Mom DRYER 1-14 - FIREPLACE r_111111171 iailrlliIUIIIIIIIIII.Tall.-IIIIIMIIIiallJ.IIIIIIrilliallBel-taiallanitli"arlltaMllaal'illIllait'llNCI-I.all— FRYOLATOR mar i 1 I' Mg"MN MC FURNACE _ .. .n. ._ .,,.m. 1111.11.1111.11 .._ GENERATOR f - ,I .y.r.. _,i ,�I _ 1[... 11 NM GRILLE l � MI r. INFRARED HEATER LABORATORY COCKS ._ - . . . s wre„ MAKEUP AIR UNIT -I _ 'MI MR - .«`maie, .:,ismilagrailiMmitimisfasiam OVEN € m POOL HEATER !...m. � __._„ .a '. _ ' . .. a,.. . ROOM/SPACE HEATER , i i . ..._, ROOF TOP UNIT m. .-1 F. _F .g�ku, ' . , TEST I - .`_ 'II UNIT HEATER �.`__ EOM --y- 1.011.1111.11111110011111 � UNVENTED ROOM HEATER WATER HEATER ` 1 ' I _., _ '.I_:. �OINIMIIMINIMMINIMIMIllatilill 11.11111111.111111i _.. OTHER I �. OM-s I W10545024$40.00 i... n _... ..,.. 1.__. C �._ pm auwomi..,r_.._r. r-„ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E,J+ . OTHER TYPE INDEMNITY in 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 u AGENT Li 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 complianc ajYPprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. %1 • !/ PLUMBER-GASFITTER NAME STEPHEN WINSLOW 1 LICENSE# 12298 SIGNATURE MP-1 MGF L JP Ej JGF U LPGI U CORPORATION +J#[3281C 1 PARTNERSHIP D# LLC Litt I1 COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE - CITY 1 SOUTH YARMOUTH STATE MA ZIP z �02664 TEL 508-394-7778 1 FAXi 508 394-8256 1 CELLI N/A jEMAILi INSPECTIONS@EFWINSLOW,COM� The Commonwealth of Massachusetts Department of Industrial Accidents =?+ h Office of Investigations 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.(R I am a employer with --- 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]** 11.0 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:01/01/2022 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: Y'�"` '`'�-" Date: 01/02/2021 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): 10Board of Health 2.❑Building Department 30 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia