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HomeMy WebLinkAboutBLDP&G-22-005595 Y . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 4/1/22 PERMIT# BLDP-22-005595 JOBSITE ADDRESS 15 BRUSH HILL RD OWNER'S NAME HILTON JOHN C P OWNER ADDRESS HILTON CAROL M 240 CEDAR RIDGE DR GLASTONBURY,CT 06033-1836 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES El NO El FIXTURES • 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 El 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 18 REARDON CIR CITY IS 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 0 0 FEES S PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • 3'" ii CITY YARMOUTH(PORT MA DATE 3/28/22 I PERMIT# 22— S f JOBSITE ADDRESS 15 BRUSH HILL ROAD , OWNER'S NAME JOHN HILTON P OWNER ADDRESS SAME TEL 860-985-3271 FAX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL El PRINT CLEARLY NEW:® RENOVATION:[l REPLACEMENT:Q PLANS SUBMITTED: YES El NOEl FIXTURES 1 FLOOR-' BSM 1 2i 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB r I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM INN lii.,MN I ! !MI MN 11111111 MN MI DEDICATED GAS/OIUSAND SYSTEM n.in iiiiil ail iiiiidiiii ii.Mini NM iii.MN inn WM MIIM,MIN DEDICATED GREASE SYSTEM NMI MN MN 111111111111 all WM WM MIN ME W I 1111111 MN NMI DEDICATED GRAY WATER SYSTEM MI IMO OM 111111111111111MN OM NMI MIN MN'ME MI MOM DEDICATED WATER RECYCLE SYSTEM DISHWASHER imeinimmommunimmonoin DRINKING FOUNTAIN MIIIII XNM IIIIIII JIM M NMI,MR MN PM MIN MI5 FOOD DISPOSER MI MIN WM' 1 an nn FLOOR I AREA DRAINmom INTERCEPTOR(INTERIOR) j iER no mm zumas. _ _ KITCHEN SINK iii.En JIM MIMI MO WM 1111111 NM W IOW IMO M LAVATORY IMO MIR—OM UM IIIIMM I 1————WMROOF DRAIN MI minorSHOWER STALL 1it muslin, ': SERVICE/MOP SINK �-�,, MIMI 111111111111111 all 11.111 TOILET NMI WM WMWM URINAL IMO WM MIMI MEI MIR MIMI 1111,111111 INN MN 111111111111 MB MN WM WASHING MACHINE CONNECTION Int1111111 MEI III 1111111111111 IMMO MIIII Mil ME WATER HEATER ALL TYPES M MB IMO MO OM IIIIIII WM NMI MK W'MN IIIIII NMI WM 11111 WATER PIPING lintlin.IMO MIIM IIIIMI MIMI WM WM MI WM OM MB MO WM MI OTHER NMI 11111 mi IOWl , 1 inininsil INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[ NO Li IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ID OTHER TYPE OF INDEMNITY 0 BOND 0 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 El 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 proyisloryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. !/ PLUMBER'S NAME STEPHEN WINSLOW __ILICENSE# 12298 SIGNATURE MPLI JP CORPORATION[)# 3281C__ 'PARTNERSHIP®# LLCO# 1 COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY-SOUTH YARMOUTH STATE I MA ZIP 02664 TEL 508-394-7778 1 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS EFWINSLOW.COM r s The Commonwealth of Massachusetts -,—N Department of Industrial Accidents _; _# Office of Investigations "�1= Lafayette City Center =='--: 2 Avenue de Lafayette, Boston,MA 02111-1750 r"MEW v 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. E Restaurant/Bar/Eating Establishment 2.[1 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 ..fic...s 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. #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. Signature: r /Yi --.' 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): 1.0Board of Health 2.0 Building Department 3.1=1 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK et CITY YARMOUTH MA DATE April 01,2022 PERMIT# BLDP-22-005595 JOBSITE ADDRESS 15 BRUSH HILL RD OWNER'S NAME HILTON JOHN C G OWNER ADDRESS HILTON CAROL M 240 CEDAR RIDGE DR GLASTONBURY CT 06033-1836 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El 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 0 OTHER OF INDEMNITY❑ BOND 0 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# 112298 I SIGNATURE MP© MGF 0 JP❑ JGF❑ LPG! ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: ISTEPHEN A WINSLOW ADDRESS. 18 REARDON CIR, CITY IS YARMOUTH STATE MA ZIP 026641207 TEL I FAX 1 CELL 1 EMAIL Iinspections(aaefwinslow.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 f , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - ll� CITY LYARMOUTH..(PORT) MA DATE 3/28/22 PERMIT# 2"2-- S cl �, im _ JOBSITE ADDRESS 15 BRUSH HILL ROAD OWNER'S NAME JOHN HILTON GOWNER ADDRESS LSAME TEL 860 985 3271 . . .... FAX ___.....-_-.. TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL L.j RESIDENTIAL] PRINT CLEARLY NEW:(j RENOVATION:L,J REPLACEMENT:12J PLANS SUBMITTED: YES 0 NOD APPLIANCES 1 FLOORS—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER u BOOSTER .� CONVERSION BURNER , _ COOK STOVE .___. .� ,_. DIRECT VENT HEATER f �� I_� 1; .__ `. .. ` I` NIB DRYER :I-- FIREPLACE G [ .. . : ... FRYOLATOR E .. I.._... .�_.. _._.. II am I � gm Ea... a .. FURNACE IIT� mi&II==inn l7-. .,. GENERATOR GRILLE I F INFRARED HEATER 11111, i LABORATORY COCKS :MI MIN MK I MI INK 111111.1.Mil NMI NM MIK MAKEUP AIR UNIT Iliff11111111111111.1111111111111.1111110111111011.iiit IIIIIIKIIIIFiiiiiirIIIIL., .m ..I OVEN POOL HEATER :. ROOM/SPACE HEATER all Nraii iic w ROOF TOP UNIT tiE TEST iim MI . UNIT HEATER M � '` I ;NN UNVENTED ROOM HEATER 1011111111111111011.IIIIIIIIIII M' 'IIII'NI"OM INN IIIII INK la .u......< WATER HEATER ____ __ ___ OTHER mE aapa, i INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ild NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 17j OTHER TYPE INDEMNITY jj 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 Ej AGENT 0 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 st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli'anncc a dine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. . !i/.__- PLUMBER-GASFITTER NAME,STEPHEN WINSLOW LICENSE# 12298 1 SIGNATURE MP MGF D JP D JGF 0 LPGI LI CORPORATION izi# 3281C I PARTNERSHIP LI# LLC 0# COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS[8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE 1 MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 1 CELL N/A EMAIL.INSPECTIONS@EFWINSLOW COM 1 The Commonwealth of Massachusetts Department of Industrial Accidents �w 'it Office of Investigations ��` �,0=7 Lafayette City Center Vt 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.Ili] I am a employer with 99 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.❑ 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. 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 ce\ • of the ins and penalties of perjury that the information provided above is true and correct. Si � 12/01/2021 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.Board of Health 2.❑Building Department 3.❑City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia