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HomeMy WebLinkAboutBLDP&G-23-003070 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' , , y` CITY YARMOUTH MA DATE 12/5/22 PERMIT# BLDP-23-003070 I' JOBSITE ADDRESS 121 CAMP ST UNIT 120 OWNERS NAME GLYNN PAMELA P OWNER ADDRESS 121 CAMP ST UNIT 120 WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES El NO❑ FIXTURES 1 FLOORS-4 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,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 ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 TEL 5083947778 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 I 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,"a:zt•- -_111F=j CITY [YARMOUTH MA DATE 11/28/22 PERMIT# 2 i 3o'Za ,4 JOBSITE ADDRESS 121 CAMP STREET UNIT 120 OWNER'S NAME PAM GLYNN GOWNER ADDRESS SAME TEL 508 566 2708 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL u RESIDENTIAL IA PRINT CLEARLY NEW:LI RENOVATION:__I REPLACEMENT: PLANS SUBMITTED: YES❑ NOLJ APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER iiiiiiii OM NO JIM OM INNF.. . .�, ,,OM PM Ilnl in*MI;OM BOOSTER �a.... l 1 . U CONVERSION BURNER ININI 1 [ [- 1 i COOK STOVE DIRECT VENT HEATER F 1 :[- [ DRYER _ i i OK. FIREPLACE llilOM MI 101111111.011114MUM 11111.1111.11111111JIM FRYOLATOR '. __ FURNACE GENERATOR �`, GRILLE �� - �- I �r �,. , — °i INFRARED HEATER IIIIIIIIIII MB IIIIIIII MM.IIIIIIIIIIIIMIll MIK IIIIIIIIIIIIIII LABORATORY COCKS Milt OM SIM MON NI IIIIIIIIIIIIIIIIIIIIIIII, MI MAKEUP AIR UNIT in si--- 1---- --- --- _ litliii OVEN POOL HEATER ROOM/SPACE HEATER ... {n r ; � INK MR ROOF TOP UNIT ;? i TEST SWIM 111111110111111•1111 IIIIIIIIIIIIIIII NM Mil NO,... MI IIIII:OS UNIT HEATER Wle WWI 3 UNVENTED ROOM HEATER ; Me NMI _ WATER HEATER _. _ 1M nt OTHER _ _ NM M---MI 0111111 MI NM IMIIIIIM MI NM NM VIII ON INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 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 __ 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 ED 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 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 a rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C • 4,...Y "` PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 1 SIGNATURE MP MGF Li JP[J JGF J LPGI CORPORATION[.# 3281C PARTNERSHIP LJ# LLC Lj# COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING]ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH 1 STATE MA I ZIP 02664 TEL 508-394-7778 FAX 8-394-8256 J CELL N/A- EMAIL INSPECTIONS EFWINSLOW.COM I . • The Commonwealth of Massachusetts Department of Industrial Accidents __ 1= Office of Investigations IT ail=_ Lafayette City Center a •--r` 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/EatingEstablishment 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. 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.❑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. 1 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 cer ' of the ins and penalties of perjury that the information provided above is true and correct. Signature: 7' 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 f Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑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 " •`M ' BLDP-23-003070 • ., -, CITY YARMOUTH MA DATE December 05,202: PERMIT# JOBSITE ADDRESS 121 CAMP ST UNIT 120 OWNER'S NAME GLYNN PAMELA G OWNER ADDRESS 121 CAMP ST UNIT 120 WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ED 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 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 I 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 El NO El 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❑ MGF © JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 02664 TEL 5083947778 FAX CELL EMAIL inspections(a)efwinslow.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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' wn " I_ - So70 _�_ui IS CITY YARMOUTH 1 MA DATE 11/28/22 PERMIT# `Z. JOBSITE ADDRESS 121 CAMP STREET UNIT 120 OWNER'S NAME PAM GLYNN POWNER ADDRESS SAME TEL 508-566-2708 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL [I RESIDENTIAL ID PRINT CLEARLY NEW:® RENOVATION:Li REPLACEMENT:Ej PLANS SUBMITTED: YES® NOLI FIXTURES 1 FLOOR—) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE MN MMI NMI NWMNEN MIN MNNE MR IIIIII MN DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM NM 111.IIIIII INN UN J MI AM INN NM NE NM MI DEDICATED GREASE SYSTEM 11101 Ng_=OW=W MK 11411M111 MAW=UR UPI Mili DEDICATED GRAY WATER SYSTEM INNINN M N 1111111111111111 NM MI an IIIIN I ,_ MN MI DEDICATED WATER RECYCLE SYSTEM j j DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) BM 1111111111111111111 IOW UMW WM I,IMO MIMI 111111111111111111 IMO MI KITCHEN SINK LAVATORYills ROOF DRAIN SHOWER STALL '� '' �;MN 111111011116.11..11111 ingalli J SERVICE/MOP SINK MIIIMIN NM I TOILET WIMP NM INK Olt M. .MR ill NMI URINAL M MN NM 111111-111111111 Ong NMI IIIIIIIIIIIIIIII AN NM NE N WASHING MACHINE CONNECTION WATER HEATER ALL TYPES OTHER WATER PIPING Ilig mason m mmiliii NE I.mi UM MUM"Mg MUM 11111111111111111011 MN MIN— NMN— NMI NM MN MIMI 11.111.111111111111111111111.11111111111111111 NM NM _ II NM NUM 1111111 11111111111111111111111' INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY El BOND L] 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 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 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 Ii with II ertine proyisiy,of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 J SIGNATURE MP JP CORPORATION 3281C jPARTNERSHIPO# ...LLC®# j 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 1 CELL N/A EMAIL INSPECTIONS©EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations rLafayette City Center 2Avenue 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): 1.11I .® I am a employer with 99 employees (full and/ 5. ❑Retail - or part-time).* - 6. ❑Resra-urant/BartEaating 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]** 11.0Health 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 cer �ee the ins and penalties of perjury that the information provided above is true and correct. Signature: . 7y�'� /.�.•/•.-�- 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 2.0 Building Department 3.❑City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia