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HomeMy WebLinkAboutBLDP&G-23-005082 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 3/15/23 PERMIT# BLDP-23-005082 j JOBSITE ADDRESS 481 BUCK ISLAND RD UNIT 7D OWNERS NAME SUSAN EATON P OWNER ADDRESS 10 SOUTH ST UNIT 1-4 DENNIS PORT 02639-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES NO❑ FIXTURFS z 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 0 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 W298 SIGNATURE MP ❑ JP El 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 y „"st. ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ FEES$ PERMIT# PLAN REVIEW NOTES , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK —mail =aii=~ IMA DATE 3/10/23 I PER P 2-3 00 S of 2, �—,C CITY Yarmouth JOBSITE ADDRESS 481 Buck Island Road Unit 7D OWNER'S NAME Susan Eaton POWNER ADDRESS same I TEL 774-487-7792 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL El RESIDENTIAL El PRINT CLEARLY NEW:❑ RENOVATION:® REPLACEMENT:Q PLANS SUBMITTED: YES 0 NOQ FIXTURES 1 FLOOR-, 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 �i a.... DEDICATED GAS/OIUSAND SYSTEM 111110111111111F111111111131.1111.111111110111111111111111WW1111111 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEMI .. _ , DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER 11111[1.11111111rillillIIIIIIIIIIIOIIIFIIIMIIIIIIIIIIIIIIIIIIIIIIIIIIIF FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINKII LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL 1, .-_ ' WASHING MACHINE CONNECTION ;' is WATER HEATER ALL TYPES QNMI MOB MN WM Mill MN WM' Mill NM ^-_ WATER PIPING ,, 1 OTHER �, 1� � - .._:_ 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ei NO Li IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - --LIABtLIMNSURANCE-POLUCYY -- - -OTHER-TYPE©€INDEMNITY 0 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 © 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 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 proyisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r - ,.....,.r..�- PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP El JP❑ CORPORATION Q# 3281C PARTNERSHIP©# J LLC®# , COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP -02664 TEL 508-=9427- 8 ECEIVFD FAX 508-394-8256 CELL N/A 1 EMAIL INSPECTIONS@EFWINSLOW.COM ------ ----- �'— MAR 15 2023 BUILDING DEPARTMENT yY .___— \ .'+► The Commonwealth of Massachusettsta .- Department of Industrial Accidents a_:_ ►-' Office of Investigations =1111_ Lafayette City Center _'i2,� 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.Fa 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. El 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.] 12.1=I 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:23 Commonwealth Avenue City/State/Zip: Chestnut Hill, MA 02467 Policy#or Self-ins. Lic. #2019A Expiration Date:01/01/2024 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. •�7 Signature: Y �f/"` ,�..,�'� 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): 10Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.00ther Contact•Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r �__• � CITY YARMOUTH MA DATE March 15,2023 PERMIT# BLDP-23M05082 I' aV a JOBSITE ADDRESS 481 BUCK ISLAND RD UNIT 7D OWNER'S NAME SUSAN EATON G OWNER ADDRESS 10 SOUTH ST UNIT 1-4 DENNIS PORT 02639-0000 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 © 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❑ LPG! ❑ 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 GAS FITTING WORK 'ilia; CITY Yarmouth I MA DATE 3/10/23 P ICI # 23 SOS JOBSITE ADDRESS 481 Buck Island Road Unit 7D I OWNER'S NAME Susan Eaton I OWNER ADDRESS [same I TEL(774-487-7792 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL U EDUCATIONAL ® RESIDENTIAL EJ PRINT CLEARLY NEW:Li RENOVATION:..,1 REPLACEMENT:0. PLANS SUBMITTED: YES 0 NO APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .A .«° BOOSTER II IIIII1. IIIMIIIIIBIFNO FMTFIIIIII J CONVERSION BURNER 1.111.11111.111.111IINN 11111111111 1111 11 ; COOK STOVESTOVE ion Mg mg limiiii.am limit pan MN WINK DIRECT VENT HEATER 11111111111111111111111111111 iiiiiiiiiiiiiiiiiiiiiiiiirunir DRYER ,_ ! 'i _ Il ' i 11i'I � i i j FIREPLACE -; O O IMIIIII,MN NMI FRYOLATOR 'Mir Milliiiiii, . 1W 111111111111w wpm FURNACE I ., .. _ GENERATOR MNMal -, ry ` INN GRILLE 11111,M111111 NM[11111111111W INN 11111 NM'Ii Mt NIX ell NM INFRARED HEATER ='11111111111111111111111111M11111 Man'Illarill.: l LABORATORY COCKS NM OM 1.111111111111111111111.01111111111 MI WAR OM NM 1110111 NO ON N MAKEUP AIR UNIT 11111111111111011.11111111111111.1111111111111111111111111111111111111111111, OVEN 1111111111W111,11111111 autaiiiiiimunimet milt 1111111111111111111111111 POOL HEATER N. ���;�' ���� ����, ROOM/SPACE HEATER IMO 111.11111111W MIR MB m; ROOF TOP UNIT 11111 ; ' TEST UNIT HEATER _ I, 1 UNVENTED ROOM HEATER WATER HEATER ��M� _ ��M���� � � � . d OTHER 1, ! �m 9 i •,, , ; I ,,�.._ .,_ ,-_ ., on I ! INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO r I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY A OTHER TYPE INDEMNITY BOND LI 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 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 complianc a YPprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. "1 )_I • !/ — PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 1 SIGNATURE MP(,„J MGF LJ JP ElJGF LI LPG! CORPORATION ,J# 3281C j PARTNERSHIP Lj# LLC #L COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING j ADDRESS 88 REARDON CIRCLE CITY SOUTH YARMOUTH STATE[ MA ZIP 02664 TEL1508-3 94WII8 RECEIVED FAX 508-394-8256 CELL N/A 'EMAIL INSPECTIONS@EFWINSLOW.COM MAR 15 2023 BUILDING DEPARTMENT By - - - The Commonwealth of Massachusetts _ Department of Industrial Accidents =_' —' Office of Investigations ' Lafayette City Center E'= 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 120 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. El 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.] 12.1=I 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:23 Commonwealth Avenue City/State/Zip: Chestnut Hill, MA 02467 Policy#or Self-ins. Lic. #2019A Expiration Date:01/01/2024 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 er the ins and penalties of perjury that the information provided above is true and correct. Signature: 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): 1OBoard of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia