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HomeMy WebLinkAboutBLDP-18-006737 tG - Coy.-I--r w :.'e MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK tr_?c CITY[ _47.• __ . v 7z .,,-e u_ MA DATE r , c. l PERMIT# I a1 f 40 �` °7 JOBSITE ADDRESS [Z2_pj#Aaf Are ,l OWNER'S NAME[ g ky A c Ot'iYG4.- ,. POWNER ADDRESS( 1..Z _ _ j TEL 5ef .v51YYo FAXL___ ___I TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL 0 RESIDENTIAL% PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:2j PLANS SUBMITTED: YES 0 NOE] FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB - - I ---- t— .�I - I I _ • ___1_ -__ _- 1 -- -- - -- CROSS CONNECTION DEVICE ( _ _ _ (_ I DEDICATED SPECIAL WASTE SYSTEM II - II . . II I I I L I I DEDICATED GAS/OIL/SAND SYSTEM (_ Y�` __ I __ I I_T 1-.-- 1-1----1-71--- DEDICATED GREASE SYSTEM I Y I ( DEDICATED GRAY WATER SYSTEM l� ���I ®��I ���I ��� DEDICATED WATER RECYCLE SYSTEM - �� Ii1 WSOMM® 1 � F m ®in OD DISPOSER. a �iss� FLOOR/AREA DRAIN KITCHEN SINK .1111.1—: PES( I. LAVATORYINTERCEPTOR INTERIOR Millitilli1111111-11111111111111111111111111 Mil I"- I_ -- ( I- 1— i�I- --I_-- 71 . 1T ; SERVICE/ O• I-- . . I f �" f I TOILET ��'� �_ �in���I - flfl URINAL111111111111111111111111 _ I�'fl'f®I fl I PIPINGWASHING WATER WATER 'iJUN OTHER sii � I ��a ISI . ���� \r.] 111 Mall _ _ �1_ MUM I SI ss� sfli fl INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW A UABIUTY INSURANCE POLICY 4:J OTHER TYPE OF INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER:l 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 D 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 d 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 comp!' ce with all Pertinent prevision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. V.1.4e. . J PLUMBER'S NAME)STEPHEN A.WINSLOW , , , ]LICENSE#[12298 SIGNATURE MP ✓I JP CORPORATION[# 3281C PARTNERSHIP 01/1 JLLCD# , COMPANY NAME!, E F WINSLOW _ 99 ADDRESS 1I8 REARDON CIRCLE J CITY I SOUTH YARMOUTH . _ .i STATE MA ZIP 02664 — —~ ry TEL 1.50,1„89____4 7778 J FAX 508 394 8256 CELL EMAIL ACCOUNTSPAYABLE@EFWISNLOW.COM I — =1= — Department of Inaustrietscctaents il . Eli ii Elkin=% Office ofInvesa:aidoiiw l ' i_ y' 600 Washington Street " — d Boston,MA 02111 =,t Www rates gov/dda • Workers'CompensatiomIInsurance rl.davit:l$a. ;dere/Contractoffs/I+;Ileetrieieals/Ph1&oeffs Msllslicant Information Please Print Legibly .• Name(Business/Organtzationandividual): E ic.w t n51 ew Y 1V,,.,idp l,tei a.1 c t-\". , `m, I cit. Address: ' &ecc&tn (11trjAh_ • a City/State/Zip: Soo kint Yate-a.,(-tn sPc Phone#: 153 -YTS-TM . Are you an employer?Check the appropriate box: Type of project(required): ., rI am a employer with /0 4. 0 I am a general contractor and I 6. 0 New construction ,employees(full and/or part-time).* have hired the sub-contractors 1.0 I am a sole proprietor or partner- listed on the attached sheet.s 7. 0 Remodeling •• ship and have no employees These sub-contractors have 8. 0 Demolition - - --- - . -. . • working forme in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its • required.] . • officers have exercised their 10.0 Electrical repairs or additions 1.0 I am ahomeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions myself.[No workers'comp. 0,152,§1(4),and we have no 12.0 Roof repairs ;, insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] my applicant that checks bole Hl must also Ell out the section below showing their workers'compensation policy Information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. :ontfaetors that cheekthtsbox must attached en additional sheet showing the name of the sub-contractors qnd theirworkers'comp.policy information. bin an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1 iformdtion. /�A`C_ • 3 . llisurance CompanyName: y()u.S' r\i kaA ,a ruici.ft 62_ \n eU,a/tkiii olicy#or Self-ins.Lie#: MSai A Expiration Date: (—l— Dor . )b Site Address:,).3 GMrvwtt tov-'0 [4h /Wy ad1/014 t11tb11 City/State/Zip: 6e)4 t,7 .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ' , allure to secure coverage as required under Section 25A of MOL e.152 can lead to the imposition of criminal penalties of a no up to$1,500.00 and/or one-year imprisonment,as well as civil penalties lathe form of a STOP WORK ORDER and a fine fup to$250.00 a da against the violator. Be advised tt a copy of this statement may be forwarded to the Office of tvestigations the DIA for insurer- ,overage verii a on. r do hereby call un ens an penalties o pe jury////// that the information provided above Is true and correct. igna c. Date: b. I a0[ hone it: ..Si7'i•3tN• 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(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other kt ' ContactPerson: Phone#: 1 MASSACHUSETTS UNIFORMAPPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK getW- Ilr CITY . 50 ug 7 ' 9 /e2,14,w .. -( MA DATE 5A3j el" IPERMIT#/.F^reL ffi"V 6777 JOBSITEADDRESS; 707 .JJ/T,../e pgdL•' !OWNER'S NAME inti i e—ren' 1 G OWNER ADDRESS ' 4q-' 5-4P`2/,f_ I TEL oP eyga 1FAXr i TYPE OR OCCUPANCY TYPE COMMERCIAL;,-) EDUCATIONAL J RESIDENTIAL i' PRINT CLEARLY NEW:'.,,j RENOVATION:•_ REPLACEMENT: PLANS SUBMITTED: YES.) NO CI APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BOILER !--_ I _ I_..D. ..- _1 ---_j;__I"",__jr l'_I.�-I'J-I= [__t ' BOOSTER :____i i _..J'_._.II_Di .__. 1 J_I _-_..J_-._J.L__L_--3 !-- CONVERSION BURNER _.....1 . J!..JJ v._-_11._--._1....__J i___..J... _1 _----1:---I _._j - -1-_.11._i___J - COOK STOVE . I _ _1 f y ! I 1! I '' '_ M! DIRECT VENT HEATER i,,__J I:___._J.__ i i. _-.-Js i_._,J ---J„---!-----! l DRYER 1_____''_.J .._.._1'__.I.___...J!, „i 1_1 I._,_J'_..,„I._. -.I'._._.i „_._..I FIREPLACE I i, 1 ' i _r_i. •___i FRYOLATOR - .� 1' -- J'_.._.l_ ...! _- 1' J ___ FURGERNACE AEOR 1_�' _.i,I I_.,.1Lb. '___Ji....J ___!._.J _. 1-__._.I' _ .--I -- - i• GRILLE . ..',�. i INFRAREDHEATER _-. I; _._ I_ j . _ I: _. ' _. .I_I -._ 1 1 __ I LABORATORY COCKS 1.__..._ I _• 1 _J ' - 1 _.-._ I .._ i_ 1 I MAKEUP AIR UNIT OVEN 1 • ' I: I _ i'. I11_......a. I,gar^1 ._J,. ..1t-.-_1:Li..,,.�J,_... .I . POOL HEATER i —'' —' I .:i , t I c- I' -II' —1 1 —1:.1 ROOM/SPACE HEATER I' _-li I I __I I _.-_I .___I- __..1 ' ROOF TOP UNIT •_.,,_ 1 -�I ,-. ,_. X1'-1; . _` 1—J =' - -1--J .,..:;.,..:;:4- --1- TEST .___I-_J____' i 1�1 1—!_1_.___'____I_ 1__-, 4.:il . . _._ . - UNIT HEATER '_1 I' 1� �. 11 I I��'_. _ ._1 _____:_._,_..f i'.--- --"'-1 UNVENTED ROOM HEATER _J _I l_1'-1-1 ':`i_-J_„„.-.11,1„__i_ --1 -J--- —1 WATER HEATER . ...... ........ _.. . . ,--7 ..i . . .. 1-.... -I.^_1- I I -- I ._I IL__1.__I __ --! OTHER:.._... ._- ._ ..-._ .._ ._ . . ..L... ..I . . ..I . ......) .-.. !; 1-�. I ...__. 1=_ ! __J i__ ..J .... 1 — ! ,_ CJA I1_..1. . . ,l . ._ 1—..1x...1--I ___J..J _-_111.1'..:=1__;!....-1._-J INSURANCE COVERAGE NJ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IA NO _i / ,1 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW W LIABILITY INSURANCE POLICY :+J OTHER TYPE INDEMNITY J 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 i_ J 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 ig 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 compile r:with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4p, / - / ..DOaz PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW ' [LICENSE#:12298 SIGNA URE MP -..-Li MGF,.,,.J JP ._J JGF:,J LPGI _J CORPORATION.1,1# 32.8{6 1PARTNERSHIP.,..I# 1LLC J#. f COMPANY NAME E F WINSLOW PLUMBING HEATING {ADDRESS•8 REARDON CIRCLE • CITY SOUTH YARMOUTH STATE(' MA, ZIP 02664” /TEL:B08194 7778 ^I FAX 508 394 8256 CELL N/A I EMAIL'accounts a able efwinslow.com DeLtipartment of lneustrtnacctaenns am1=72- Q Office o investigations ci =VC= .1 600 Washington Street 7=:i.i= x Boston,MA 02111 • °•;, * WwWenassgov/iiia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Pltanlbers Applicant Information /� Please Print Legibly . Name(Business/Organization/Individual): Esc.W1,�SIow rlVm]oinee, �4.l1t,e��, Cm, I✓tt, Address: c' KPOt�bn ('jJt . 1 City/State/Zip: Soo kh .3in 1•lPr Phone if: `518.39`1'-1'1?fit Are you an employer?Check the appropriate box: Type of project(required): • ,, I am a employer with 70 4. 0 I am a general contractor and I 6. 0 New construction •employees(full and/or part-time)."' have hired the sub-contractors t.❑ I am a sole proprietor or partner- listed on the attached sheet.t ?• 0 Remodeling • ship and have no employees These sub-contractors have 8. 0 Demolition - ' working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. 0 We are a corporation and its • required.] officers have exercised their 10.0 Electrical repairs or additions I.❑ I am a homeowner doing all work right of e:femptlon per MGL 11.0 Plumbing repairs or additions . myself[No workers'comp. 0.152,§I(4),and we have no 12.0 Roof repairs . insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] lay applicant that checks bold I must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work end then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name Mho sub-confactorkstud'their workers'comp.policy information. Am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy and Job site 1 Iformdtion. /� � • itsuranceCompanyName: trl'(YO+.i rkkAnic.Jt [.....1:111.11/4/a it C/2 \(1 uv tl''11 olio),#or Self-ins.Lie.#: I$a I A Expiration Date: c--i Doll . )1)Site rvnw2 �aJill 1 / 0\e•311141•6 fnI bCity/State/Zip: COL;to7 .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ' • allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a \' ne 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 flip to$250.00 a da a a nst the violator. Be advised t at a copy of this statement may be forwarded to the Office of `1 tvestigations the DIA for insurat�e •.overage veri on. t . do hereby cert fy um• e pains an.penalties o pe Jury that the Information provided above is true and correct lgnai4. !(1^" rn Date; [Ill 31lam( hone#: .ci)1.31`y- 7 77g Official use only. Do not write In this area,to be completed by city,or town official • City or Town; Permlt/Llcense# kit Issuing Authority(circle one): �.( 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector \ 6.Other Qk Contact Person: Phone#: - l� N