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HomeMy WebLinkAboutBLDP-19-001031 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Lt�I��/ 'M/� 7 . --z-ri 4------ j CITYI YAM/1041k MA DATE / 1//Ali PERMIT#i JOBSITEADDRESS Saw QS be 104 OWNER'S NAME !Actin y1?l 1/1c1-mews P OWNER ADDRESS IA Noblo3 Ld#e ihftoil HiMlk { TEL 6119O1sS1.."1 FAX Inn TYPE OR OCCUPANNuYTYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIALD PRINT CLEARLY NEW:0 RENOVATION:O REPLACEMENT:Q/ PLANS SUBMITTED: YES 0 1\100 FIXTURES 1 FLOOR-. BSM 1 2 © 4 5 Q 7 00 10 11 12 13 In BATHTUBINIIIIMINIIMI—NeNNIMININIMMIMIIINNIN CROSS CONNECTION DEVICE ell MN NE®:=INN INN MI®11111I•.®OM NE MN DEDICATED SPECIAL WASTE SYSTEM IIIIII NM MN 5ummos f,ssoosIle nNW DEDICATED GAS/OIL/SANDSYSTEM NSEin,magi rim ma Noam_a1Mla*IMAM DEDICATED GREASE SYSTEM ME w NM w'MI NIII ell EN w MIN rile'` M Ile f INN DEDICATED GRAY WATER SYSTEM INII NM MI m; 111.En MN NM IMIIsr s a MN DEDICATED WATER RECYCLE SYSTEM MK MI MIN Ea; ,nimi,m,I♦i.al,im,.n DISHWASHER NMwa_I=MS_MINMO,SMIMIS ME DRINKING FOUNTAIN 1.1.,..NM=WINN f,M M:MI Sas FOOD DISPOSER Man SUSS= ou fl Is la MKS FLOOR/AREA DRAIN NMI I•IlleN,ell—ell MEM—'—,®MI INTERCEPTOR INTERIOR 110.I NM IM;I♦5—fl_—flfl 7 ME KITCHEN SINK 5MN IME M;MI_=INE MI♦-1NMMIMII LAVATORY —.MN MI INN,I.TIM,MME.NEI 5;MI I5,Ne M S _aNEsmistSa sin SHOWER STALL MS= 5,_" ION IM at S is Am S is is SERVICE I MOP SINK �MII��,� ROOF DRAIN �slim ell IM ell NIN IMAM SIM NM MN TOILET NEI Nell 5MIOMIMN55Ile 5NMIMI URINAL M5 Eli 0 SflNI♦:MIIIIII Slel EN WASHING �iS IM INN WATER WATER PIPING RIALL TYPESCTION S==,=�=„=5=S,IS Mil OM_—ell OTHER M IMI 5 MICOM,.,INE 5 MINMI♦ON,1.111,1M IME I=I=MN MUM sIMM_iNiMIE_SNEaOM MININIIIIIIIININIMINIMIIN IN Ste,Nan - s SIM MINN"M le,I�� NIIIIIIIINIIIIIIIIINIIIIIII _____5_NININI' 'V S AM INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D 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. CHECK ONE ONLY: OWNER 0 AGENT 0 0 SIGNATURE OF OWNER OR AGENT 1/4.P. I hereby certify that all of the details and Information I have submitted or entered regarding this application are try.):nd 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 co nce with all Pertinent provision of the + Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i cJ% �a_ - - c' PLUMBER'S NAME I STEPHEN A.WINSLOW ILICENSE# 12298 • SIGNATURE MPD JP CORPORATIONQ# 3281C PARTNERSHIP❑# LLC❑# rC COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 1508-394-7778 r_ FAX 508-394-8256 CELL N/A EMAIL I accountspayable@eiwinslow.com I • OYb\ l,{6 l.V,.H,sV,.rr._s. .,.O, 41•.0601.•••••••141S“.0 1 =ir_ Department of Industrial Accidents•= ni l Office of Investigations =Apt= 600 Washington Street ' r. Boston,MA 02111 '."= www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E•c.W,,ksiow et�,..,6 � .& lc0.\-s,nc CQ, ante Address: g Qeo�dttn elmal . Q OY City/State/Zip: Souk krc-,cs tin h4Ac Phone#: 'OS-399-111'751 Are you an employer?Check the appropriate box: Type of project(required): ," am a employer with '70 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction :.0 I am a sole proprietor or partner- listed on the attached sheet.t 7. 9 Remodeling ship and have no employees These sub-contractors have 8. 9 Demolition working for me in any capacity. workers'comp.insurance. 9. 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 exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.9 Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.0 Other thy applicant that checks boil#1 must also fill 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 a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site formation. /�� � Isurance Company Name: /kt m,-1 61/411-1.13-4 r7.f n te_ e try olicy#or Self-ins.Lice.^#: 1'sal A Expiration Date: (-1 — aol9 Ib SiteAddress:a3 G.r• .n,hee_11h, A,r2/ CPeg ,I{. I-Vil1 City/State/Zip: 0314[07 ttach a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a I tie 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 11 'up to$250.00 a da a:ainst the violator. Be advised t..t a copy of this statement may be forwarded to the Office of vestigations . the DIA or insurar - overage veri•on. ' da herebyr( certify un - e airs a penalties ojury •that the information provided •above i true and correct 1%.\ Al gnatuT: Date: la 1 aot7 " rove#: Stag=35`1. 7 77g Official use only. Do not write in this area,to be completed by city,or town official • City or Town: • Permit/Licehse# Issuing Authority(circle one): N 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other r • Contact Person: • Phone#: Q t 1 � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '•,_ -lce e CITY Y(PM0U4-vt I MA DATEEJIU t PERMIT#61-DP—MX/0 9/ JOBSITEADDRESS SgdYl-( (]..S Ile/0w OWNER'S NAME t4(OA Ire IVIQ'iIi{WS- i GOWNER ADDRESS ,_ A A. r U : i. . TEL cllgo!SSa1 IFAX TYPE OR OCCUPANCY TYPE COMMERCIALD EDUCATIONAL❑ RESIDENTIALW PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:a PLANS SUBMITTED: YES❑ NOD APPLIANCES? FLOORS—. BSM 1 ' 2 3 4 j 5 j 6 7 8 9 10 11 - 12 13 14 BOILER _ —_.- ____ BOOSTER CONVERSION BURNER MS, _- _ COOK STOVE 1 — __ DIRECT VENT HEATER - DRYER r -s - FIREPLACE FRYOLATOR FURNACE a GENERATOR GRILLE INFRARED HEATER, LABORATORY COCKS I MAKEUP AIR UNIT OVEN r _ • POOL HEATER 1 ROOM I SPACE HEATER l ROOF TOP UNIT TEST UNIT HEATER r rt UNVENTED ROOM HEATER WATER HEATER OTHER ME - _ M A. - I a 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 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑' OTHER TYPE 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. 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 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 com' •nce with all Pertinent provision of the t, :Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i A PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 . ' SIG 'TUR ( o MPD MGF❑ JP JGF❑ LPG(❑ CORPORATION Q# 3281C PARTNERSHIP❑# (LLC❑# rar COMPANY NAME. EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE 1/41E' CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 I FAX 508-394-8256 CELL NIA (EMAIL accountspayableaeefwinslow.com U � a 3 • S. \ 1 I14 .JVIIMIws.IIII/I.I.j 2ra..4JMYIlnaf..Oa -,--E. Department of Industrial Accidents 1 EMI_Oft Office oflnvestigations t _''` � = 1 600 Washington Street Boston,MA 02111 r- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgganization/Individual): Ef.WtASI Ova Ylk.,6-1 Vit0.1- , Ielt. Address: S' &eocltul C*ctQ. d Cit City/State/Zip: Sas Ycrc,c,,,(t•, t4Ac Phone 11: `5(E-399-11/SE Are you an employer?Check the appropriate box: Type of project(required): Xam a employer with 70 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors .❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. 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 10.0 Electrical repairs or additions required.] officers have exercised their .❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 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 bol ill must also fill out the section below showing their workers'compensation policy information. iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. / � I tsuranceCompany Name: fTrYp.,.� t%ukcA ( f3fcnt_p_ Cats. pin" )licy#or Self-ins.Lic.#: I S a I /Sr o �==i 9 ('� ��"" ''11 Expiration Date: �—] — a01 tb Site Address:.23 Merl�eJ4h A-0-4I CPe3 14Il� � City/State/Zip: Ory 107 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Inure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 1 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 1 F up to$250.00 a da a ainst the violator. Be advised ti.t a copy of this statement may be forwarded to the Office of tvestigations the DIAlfor insurage )overage veri a, on. do hereby certify un • ' I1penalties I p•jury that the information provided above is true and correct i_ at& • or / . . a Date: la I ROI' (� hone#: bt 3 l`1: 777g .` Official use only. Do not write in this area,to be completed by city,or town official • City or Town: Permit/License# R Issuing Authority(circle one): ‘$)•S � 1.Board of Health 2.Building Department 3.City/ own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other \ Contact Person: Phone#: