Loading...
HomeMy WebLinkAboutBLDP-18-007397 QQ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ___ fi t CITY tgfg .1yFr�mR_SC� ., r_. MA DATE itaLcjA°�JPERMIT# ✓ --e'° •"•7 JOBSITE ADDRESS 40 J Pe.A! e7 7 _ ,� rE j OWNER'S NAME[ t cC ,_5C O'er P OWNER ADDRESS TEL 5; 760 ?366 _FAXL TYPE OR OCCUPANCY TYPE COMMERCIAL0 EDUCATIONAL 0 RESIDENTIAL /��� PRINT J CLEARLY NEW:0 RENOVATION:[ REPLACEMENTS PLANS SUBMITTED: YES 0 NO[__] FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ®INIS®111.®1111111111111111111.111111®®®®® DEDICATED GASIOIUSAND SYSTEM M®®®®®a®®®1111®111111 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEMallilln—ag—®INIMISSIIIIIII®SMINI DEDICATED WATER RECYCLE SYSTEM IaaapillaNNIMIllanaill ®ilinnil DISHWASHER ���' ���' �� DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN IIIIIINIIIMMENINIES111111111111111111.11111111111111111111111111.1 INTERCEPTOR INTERIOR 11111.111111111111111111111111111.111.111111.11.111.111111111111111/111 KITC EN SINK LAVATORY ROOF DRAIN j iiIININ® EMIS®11111i_s1111i_aim SHOWER STALL SERVICE I MOP SINK TOILET 1111111111111NINSIIIIIIMMINESSIMINEN11111.111111111111 URINAL WASHING MACHINE CONNECTION MillillS11111115111MINa1s1S 1 •E WATER HEATER ALL TYPES OTHER <� . / I Ii ��� ��� �� _ WATER PIPING 5's__s__i_a.si� i_ne 11111111111111.111.11.1. v INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO CJ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY] BOND El 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 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are rue 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 Inc pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME STEPHEN A.WINSLOW LICENSE#112298 S NATURE MPE41 JPO CORPORATION[71# 3281C_ PARTNERSHIP#1, ,. JLLC0#r, 71 COMPANY NAME LEIMLOSaa Wim. ADDRESS 18 REARDON CIRCLE 1 CITYI SOUTH YARMOUTH _ J STATE v ZIP 02664 TEL 1.6126194 7778 . FAX 5_083948256 . CELL IEMAIL LACCOUNTSPAYABLESEFWISNLOWCOM __ _1 G2 �)- • ! I, Department ofh000gstrtafAccttaents it i=t Office oflnvestdgatioass e _ t lengton Street e.="tk•-_s i 600 W Boston,A 02111 y�:�- rt w a nasigovklia ' Workers'CompernsattloaaIInsurannce 'davit:llitailalers/Contractors/lElectxiclans/Plmaniters M wllcant Information c Please Print(Legibly .• Name(Business/Organization/Individual): E f.Wrf51 OW OVas‘]oivtc� 4 0?RI" Qn, I✓It• Address: 7' a.eocat1 Cat . • CitylStatelZip: Sodic C). tel MP( Phone#: &Db•3(19r117V • • 4Are you an employer?Check the appropriate box: Type of project(required): I am a employer with "70 4. 0 I am a general contractor andI6. 0 New construction ,employees(full and/or part-time).* have hired the sub-contractors !,0 I am a sole proprietor or partner- listed on the attached sheet : 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. 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. o.152,§1(4),and we have no 12.0 Roof repairs •, insurance required.]t employees,[No workers' comp.insurance required,] 13.0 Other 1ny applicant that checks lick!!!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. :Wisdom that cheeitthis box must attached an additional sheet showing the name of the sub-contractorswith*workers'comp.policy information. int an employer that fs providing workers'compensation insurance for My employees. Below is the policy andf ob site iformdtion. =ranee Company Name: Inmi' r141107l 5-2131Y616c.2. co tir olicy#or Self-ins,Lie.##: 1 S a i A' M Expiration Date: 1—1— abt'1 • :b Site Address:, 3 G3nnrvail w.eJ4� ,k&41 CteN City/State/Zip: 6,)84&,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 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 fup to$250.00 a da against the violator. Be advised t a at a copy of this statement may be forwarded to the Office of tvestigations • the DIA for insuraie 'overage veri a on. - / do hereby certD un e e alms an,penalties o-Jury that the information provided above Is true and correct. `\ atuY Ai Date: l ell 3l l anti ...Z ‘hone#: ..501. 9.4. 7778 • Official use only. Do not write in this area,to be completed by city,or town official • City or Town; Permit/License# t. Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Awn Clerk 4.Electrical Inspector 5.Plumbing Inspector • �, 6.Other . Contact Person: Phone#: o � \ \I I WV MASSACHUSETTS UNIFORM'APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY . IT -"II? /oreuzfv77 ..[ MA DATE,,- •S-•h•t ,PERMIT# I&-4°I8-� /t 97 �/ YO(y✓- I OWNER'S NAME L... _. - sce��'� - �•� •( JOBSITE ADDRESS: ll / A i%.IS c 7Fr%A G OWNER ADDRESS ; 4 i JTELst 7 o.Ai4 . IFAX. i TYPE OR OCCUPANCY TYPE COMMERCIAL:_,I EDUCATIONAL Fit RESIDENTIAL j'1 PRINT CLEARLY NEW:'J_ RENOVATION::..D REPLACEMENT:XI PLANS SUBMITTED: YES_..1 NOD APPLIANCES Z FLOORS-0 BSM 1 2 3 4 J 5 6 7 8 9 10 11 12 13 14 BOILER i -1._.11..,i;.:_,4_1..1 1_�_ -I._-..�I.._.__J __,_....1 _.! �I..,--i�--1I..__..I— .`' BOOSTER :::11-......D.____...1 _._.J'_ —I`. —--lc _J'._,_J ....__J J_il ...__I Ii_._.f CONVERSION BURNER COOK STOVE .f„ I_ _ I 1 r___- I 1 . I __ L--._.i . I___,_;'.—J�_, DIRECT VENT HEATER 'i. . 1 I .! __.I• I i. . I .J_. r._._,»_ __i'._...), ! __-_!_____ DRYER _..__} _.__I',„___1'_._.....I'..._m i 1 _ P' P _ ' !'._ J 1'._ _i. • FIREPLACE ___ I __ I ____ I _ f ' I.__J _ I —1 i_.....! FRYOLATOR I 'i __.._J __._l ____1 ( i_._._' FURNACE I: I ( t; ,1 1 __,_J GENERATOR �I, J! I GRILLE ""'1 I - _.I_ w r _. _ _ .•.,.•— .,--m.: - •.ra,-,•I -,G--- _._.1...--,,.,J INFRARED HEATER 1 1 i i t 1 ;• s LABORATORY COCKS I I J I ___ ' --. _' _f _._! _ ( ' mr� --- sem-^ -- -" •a-' ---'-""-"" ,•• ¢ ^^--� --• �r MAKEUPAIR UNIT J I. I .. I ._. ••__ _ OVEN _j.____!'_ • I swrmat r..,..J� I` . .—.I� J. I ,.,..1 ,...,n1 ! .__J-:_rl.�,.-..t ,_.._I �wnrs-I_ _ ,i____!.. 1 .—._I _ POOL HEATER i s t: i. I_J Ti' i _ .T r. ROOM I SPACE HEATER ! ..11,-- '-- _ ' 1:— l' I'ii_(i_1_.,_,..11._.:_t _ ! _,__i ROOF TOP UNIT F r' I..„ _I' -I _41-::., --I I-, -I __2,_,._,I i —l.—I s TEST _-••_( I I t_..-_1 -7----1.--:.--7) .__,_.I_._._' .,-„-i;,....�.,J ----` •� UNVENTED ROOM HEATER _ ” J :�: ._LLD__J___I_I Tf__.1 1-_._,-i) _.J -NI UNIT HEATER 1 I' I' I' ' I ._I "Li _''.._.....J___-_,4 __,-_I WITER HEATER . I I ...I i —i �1 I - . — -_ I-i; _.. .till ' .� a ..__I r� o —JI'.. I J . . I .I_LII - I __I .. .. 1—...' .1'._..J . .....1 - - 1___.1J - .% �_J'_,._.J J' ! i' .-___J---J ._.-J'...J J2.:-__!-- vi_._..i :_i.) ... _I__ -J---.1._ _!i_.;_J.:.. -' i . - .''1ilI - 1: ' .I ---J ---! ----1 .-__I .__1.__J .. .1_LI _--1---i INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I LJ NO LI I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY al 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 1 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 compli le with all Pertinent proven of the Massachusetts State Plumbing Code end Chapter 142 of the General Laws. i • .. . • PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW #: I_LICENSE12298 SIG ATU`E MP .J MGF.,,_I JP J JGF LJ LPG! ,I CORPORATION-J#;32810 I PARTNERSHIP L!# j LLC „St. I COMPANY NAME: E F WINSLOW PLUMBING&HEATING .ADDRESS 8 REARDON CIRCLE I CITY SOUTH YARMOUTH -j STATE i MA 1 ZIP i 02664 TEL.508 394 7778 I FAX'508 394 8256 CELL: N/A I EMAIL!accountspayable©efwinslow.com I // � (Of ya leiY I • Department of IndustrialAcctaenrs st_;,moi=- Office of Investigations ., , 600 • Washington Street • t. _`l�i�='/ Boston,MI 02111 • imp www.inassgov/dia ' Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly .• Name(Business/Orgglanization/Individual): E.F.W1A51OW ClVrenloteei L q•eox: r co) Irtf co.Address: (teocktin ( ),,,k. - . _ a - City/State/Zip: So,sktn /cn ,cask' Or Phone#: 15O3-399-11i7C1 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! 6. 0 New construction •employees(full and/or part-time)." have hired the sub-contractors :.0 I am a sole proprietor or partner- listed on the attached sheet t 7. 0 Remodeling e 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.❑Electrical repairs or additions required.] officers have exercised their I.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself[No workers'camp. e.152,§1(4),and we have no 12.0 Roof repairs . insurance required]t employees.[No workers' 13.0 Other comp.insurance required.] thy applicant that checks box NI must also till 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. :oontracton that checkthis box must attached an additional sheet showing the name ofthe subcontractors:nod their workers'camp.policy Information Am an employer Mails providing workers'compensation insurance for my employees. Below is the policy and Job site 1irormdtion. nn __ n tsuranceCompanyName: t nT)+.i Ck`A-V0reIPO etett2 \ , tv .j . alloy#or Self-ins.Lk.IP. ISlaI Pc Expiration Date: C--[ - eon tbSite Address:d3 Czwevtchnk ?a-141'1 /C+t'a ONe.44 I11 City/State/Zip: Oa4b7 .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 0.152 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 in the form of a STOP WORK ORDER and a fine Cup to$250.00 a da a ainst the violator. Be advised tjigt a copy of this statement may be forwarded to the Office of avestigations the DIA for lnsura�te ,overage vers a/pion. t do hereby call&un,e e airs an penalties o pe jury that the information provided above is true and correct tguatu4ee— Date: 1 o. 3 I l 101 C T' ( bone if: .m' -'45ti• 777X 1 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): • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other . #: Contact Person: Phone l i • ' 1