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HomeMy WebLinkAboutBLDP-21-006800 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -• ,e,k c! CITY YARMOUTH MA DATE 5/24/21 PERMIT# BLDP-21-006800 11`- - JOBSITE ADDRESS 2 CAPT SMALL RD OWNER'S NAME TOLMAN-MICHON HILARY P OWNER ADDRESS 300 E 40TH ST APT 12A NEW YORK,NY 10016 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES El NO El 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/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 1 SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 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 El 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 112298 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com i 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 6-,MO, CITY v i MA DATE ( I PERMIT# al--DP- 21°061co JOBSITE ADDRESS Z CAj04-ot1‘cal Sill///qv/5, i' now4 OWNER'S NAME -- `__ c l•rt , . P OWNER ADDRESS 30C) & Li _ 1, ) •Aern/ K/k �Nj TEL S� 3l036 _'FAXL- TYPE OR OCCUPANCY TYPE COMMERCIAL ID EDUCATIONAL 0 RESIDENTIAL L PRINT CLEARLY NEW;0 RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES® NO FIXTURES 7 FLOOR—► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB � „ ;1 I _ 1 __I I J CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ,!1V . L J DEDICATED GAS/OIL/SAND SYSTEM , DEDICATED GREASE SYSTEM �� I_._._ .__- 1 �11_1�1!t��� 1�1 11 !�a :_IW--_- i, ` ililillig DEDICATED GRAY WATER SYSTEM , DISHWASHER I ___', ' 1 SFWINMFIL.: - - FOOD 1 • Y 1_,,..,_1 I I .. J milli 111 DEDICATED WATER RECYCLE SYSTEM INTERCEPTOR(INTERIOR) 'I d LAVATORY IM._. =I -•• 1•+ te r n SHOWER i _._. ii i SERVICE/MOP SINK in_._ ,_.. _ .s I al WATER HEATER ALL TYPES • RRUR'RRRRRRRR ft . t v 01Kk INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ei NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY 0 BOND D 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 Li SIGNATURE OF OWNER OR AGENT O I hereby certify that all of the details and Information I have submitted or entered regarding this application are true it a to the b t of my knowledge v. and that all plumbing work and installations performed under the permit issued for this application will be in co II with rine prglsion of the ..44s, Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN WINSLOW _—ILICENSE# 12298 SIGNATURE r MP El JP CORPORATION .+'# 3281C PARTNERSHIP-. i#_____ ._ ___1 LLC��'I#_ i COMPANY NAME E.F.WINSLOW PLUMBING&HEATING 'ADDRESS 1-8. °REARDON CIRCLE - 1 I CITY SOUTH YARMOUTH 1 STATE MA ZIP 02664 �___.-..al TEL J 508-394-7778 FAX T08-394-82561 CELLI N/A EMAIL INSPECTIONS@EFWINSLOW.COM _ 1 s The Commonwealth of Massachusetts Department of IndustrialAccidents f Office of Investigations 1 Lafayette City Center "�, 2Avenue de Lafayette,Boston,MA 02111-1750 viit 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): 1.0 I am a employer with 90 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. 111 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 10.0 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.] 12.111 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 ' ee the ins and penalties of perjury that the information provided above is true and correct. Signature: �"'. IrT/�<^--- 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 If Issuing Authority(check one): 10Board of Health 2.0 Building Department 311I City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia