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HomeMy WebLinkAboutBLDP&G-21-003309 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .. ':; , CITY YARMOUTH MA DATE 12/10/20 PERMIT# BLDP-21-003309 I' $y JOBSITE ADDRESS 8 CHRISTOPHER HALL WAY OWNERS NAME DAVIS LOUISE E HALL TR P OWNER ADDRESS LOUISE E HALL DAVIS REV LIVING TRUST 8 CHRISTOPHER HALL WAY TEL YARMOUTH PORT,MA 02675 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 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 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 m NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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. PLUMBERS NAME Stephen Winslow LICENSE 12298 SIGNATURE MP © JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 18 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections@efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK L.� � i®._- CITY YARMOUTH MA DATE 11/30/20 PERMIT# /31 ')/"a 33 5 JOBSITE ADDRESS 8 CHRISTOPHER HALL WAY,YARMPORT OWNER'S NAME DAVIS,LOUISE P OWNER ADDRESS TEL 508.362.3537 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:Li RENOVATION:0 REPLACEMENT:Q PLANS SUBMITTED: YES 0 N00 FIXTURES 1 FLOOR-0 BSM 1 I 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB e _ _ , CROSS CONNECTION DEVICE EllaBllallIlF.IIIIIMMNIIIIIIIIIIII.gillIlltnllMMPIIIIIIllIllill.FIIMI DEDICATED GAS/OILISAND SYSTEM I1DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER • IIIIIIIII 11111111111MIMMIKIIIIIIIMItION11111.. ••D DISPOSERI FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) Ellell, KITCHEN SINK _ LAVATORY I 1 1 ROOF DRAIN - ,f SHOWER 1IIIIIFIIIIFIIMM SERVICE/MOP SINK TOILET -, i i , I'f MM. , , 1 WASHING MACHINE CONNECTION 1 111.11111nnummi - . ,... , _ i WATER HEATER ALL TYPES 1 1 WATER PIPING „i...,._.. .,� ,� ...wvr- �-r r.r � � ...... � I....... .. OTHER L w.—.ter_ •-r-. -_r: ,,, e - .v x' _ s q.�.. 1 , • I ,I ,I 1 °I_ I I G., INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO L 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 El OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by.Chapter 142 offhe Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 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 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. r 1 ? `` .......''r" PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MPD JPO CORPORATION0# 3281C PARTNERSHIP 0# LLCO# 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 i y Department of Industrial Accidents ..--" • " q=jl_ l Office of Investigations .. WI MI Lafayette City Center f V.1 .' 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 90 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.E 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.❑ 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. #1909A Expiration Date: 01/01/2021 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 ' er the ins and penalties ofperjury that the information provided above is true and correct. Signature: Y,,ff//"` ' ,-- Date: 01/02/2020 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 L , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK E- - � CITY YARMOUTH MA DATE [December 10,202( PERMIT# BLD-21-003309 JOBSITE ADDRESS 8 CHRISTOPHER HALL WAY OWNERS NAME DAVIS LOUISE E HALL TR G OWNER ADDRESS LOUISE E HALL DAVIS REV LIVING TRUST 8 CHRISTOPHER HALL WAY TEL YARMOUTH PORT MA 02675 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL [] PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO 0 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 El 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❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(a)efwinslow.com —f-i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK :a,i.- tuti 7 CITY 1 YARMOUTH MA DATE 11/30/20 PERMIT# BLOC -02/-'O 33(1 JOBSITE ADDRESS 8 CHRISTOPHER HALL WAY,YARMPORT l OWNER'S NAME DAVIS,LOUISE GOWNER ADDRESS ]TEI2[508.362.3537 — FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ' RESIDENTIAL 0 PRINT CLEARLY NEW:0 RENOVATION:- REPLACEMENT:.. PLANS SUBMITTED: YES[l NO APPLIANCES 1 FLOORS-' BSM 1 l 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER MN MI CONVERSION BURNER � � 4 ,� COOK STOVE DIRECT VENT HEATER r DRYER MI' _.` ;MI FIREPLACE FRYOLATOR 31 __ 11__ FURNACE - im swim GENERATOR GRILLE o INFRARED HEATER i - A ai 'LABORATORY COCKS . .. , ;, .. E , „ MAKEUP AIR UNIT 1 �.. . L �. ,.� . � MI OVEN OR OM POOL HEATER rMI ROOM I SPACE HEATER _ ,.._ . . I . ..., n , _ 1 ' ',. „ ROOF TOP UNIT TEST UNIT HEATER `_ [ .__ _ A __ --. _ _ 11111111 UNVENTED ROOM HEATER _ WATER HEATER � � � . OTHER ME all W/O 541136 40.00 �, 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements off MGL.Ch.142 YES Ld NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX B LOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY '9OMD� - i 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 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 st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliancnc ajYPprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7.,[ • y ., -- PLUMBER-GASFITTER NAME STEPHEN WINSLOW -I LICENSE# 12298 1 SIGNATURE MP MGF j JP D JGF fl LPGI 0 CORPORATION J#[3281C PARTNERSHIP LJ# J LLC,®„# COMPANY NAME:I E.F.WIN-SCOW PLUMBING&HEATING 'ADDRESS 8 REARDON CIRCLE t CITY LSOUTHYARMOUTH i STATE MA ZIP I02664 ITEL 508-394-7778 FAX[508-394-8256 CELL NSA _ jEMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts a Department of Industrial Accidents 1 Office of Investigations ow ' Lafayette City Center �% il:!�1' 2 Avenue de Lafayette, Boston, MA 02111-1750 ,r ,. 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 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• 0 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#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. #1909A Expiration Date: 01/01/2021 Attach a copy of the workers' compensatiod 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 . the ins and penalties of perjury that the information provided above is true and correct. / 01/02/2020 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): 10Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia