Loading...
HomeMy WebLinkAboutBLDP-19-001034 O EMMA/ �. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • itj . CITY L.S.a.r.... a cc_c i MA DATE I r � idilL _j PERMIT#8.--/2/91?-00/d y L JOBSITE ADDRESS I ? isespf f?a.e &I OWNER'S NAME V (j__cd_secrats j POWNER ADDRESS I TELI,, 4337 !ysAFAXI TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:R PLANS SUBMITTED: YES 0 NOD FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB i—� --I---I ---'- I f —1-- - I CROSSCONNECTIONDEVICE DEDICATED SPECIAL WASTE SYSTEM I. . . I I I _. -_ �___-1-.1-I_ __ DEDICATED GAS/OIL/SAND SYSTEM I --- I [ 1 , - . I - � 1 1 -1- _ 1,., i DEDICATED GREASE SYSTEM _ . . _..___ DEDICATED GRAY WATER SYSTEM f �I I 1 1 DEDICATED WATER RECYCLE SYSTEM I 1 , a 1 I I I _-_i DISHWASHER wT ' I DRINKING �� _ I Il I a �In INTERCEPTORINTERIOR KITCHEN SINK �'�� Mill Sr=- SERVICE/MOP SINK alnallitlatligallESISIM -...0 TOILET URINAL iiiiiiiinistosansilissisiessas WATER HEATER ALL TYPES montanisian .11111111.1111111.11111111111111111101111111111111111111111111011011S 49 OTHERSINI111111101111011111111111111111111111311111111111111101 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[] NO U IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF 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 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 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 co ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. a /l /f/7 pu PLUMBER'S NAME I STEPHEN A.WINSLOW . . j LICENSE# 12298 / / am SIGNATURE(ATURt�G MP/] JP CORPORATION 0 #13281,C,. ,JPARTNERSHIP©#1 ., LLC[ #I _ COMPANY NAME E F WINSLOW_ _ _ ,m _ _ ADDRESS 18 REARDON CIRCLE __) CITY SOUTH YARMOUTH STATE L MA ZIP piT I TEL 1508 394 7778 FAX 508 394 8256 CELLI JEMAIL LACCOUNTSPAYABLE EFWISNLOW.COM Pelfgo 6i m= / Department o ineetstratt acculenrs r_5`' Office of'Investigations ..,.: att _ `_`600 Washington Street _ ' — ' Boston,MA 02111 ``� ' wwwsnassgov/rile ' Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Anplicant Information PleaseasPrint Legibly .• Name(Business/Organization/Individual): C f.W,,�5I ow QV��oiv�ccj a.I•l„RI, `m, I✓1f. Address: „� 6urebvl C2irtl.� • City/State/Zip: 'So,skh J-n Nps Phone#: 'SOS-3R9r1iij 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 constmction ,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.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• 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 t.0 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 wehave no 12.0 Roof repairs . :, insurance required.]t employees.[No workers' I3.0 Other comp.insurance required.] my applicant that checks box#I must also fill out the section below showing theirwarkers'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. :oonbaetors that checic this box must attached en additional sheet showing the name(Athe sub-contractors:aid their workers'comp.policy information. !m an employer that is providing workers'compensation insurance for My employees. Below is the policy and fob site 1 rormdtion. n •. r`� • 3 . tsuraneeCompanyName: 4111)+,J' (kJ IrvoJ ,1 f(r2trtCP_ \ grAytktey alley#or Self-ins.Lic..^#: osa[ /k • • iExpiration Date: t—'[^ eon • rbSite Address:. 3 Ginnewre /fua-t'�t AMy CCeg )r i 1 I` City/State/Zip: 6x467 .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 Cup to$250.00ada against the violator. Be advised at a copy of this statement may be forwarded to the Officeof tvestigations • the DIA for insure fe overage veri on. r sio hereby certi an a ;Can penalties of pe Jul that the information provided above is true and correct. 1 a h Date: (a 3 I 1 9.016:4 ( ' �� hone#: ..51)1.3114. 7 77X 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): ..... 3 1.Board of Health 2.Building Department 3 City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: c\ titika:ireavi!.e MASSACHUSETTS UNIFORMAPPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Dnp- -t7o/43!/CITY o! . a/ ._ IMA DATE 7".-i4:-/F-• IPERMIT#/%--+� 7 ■/'y • JOBSITEADDRESS; 7 tNniw 'l; R o d 1); I/ IOWNER'SNAME < a/ !`L'Air' A . a -..-•-_-. ..__•-- •_--•• _------•----•___•_• •----- . .... .. FAX:'G OWNER ADDRESS . �TEL'�t��f�pyS1 TYPE OR OCCUPANCY TYPE COMMERCIAL',j EDUCATIONAL[,J RESIDENTIAy PRINT CLEARLY NEW:D" RENOVATION:•.J REPLACEMENT:id PLANS SUBMITTED: YES LI NOD APPLIANCES T FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ( . _J, _1_.._..., - y ......} _ ... T .._ I _J —!i_� BOOSTER ,.__.-I_-.__I, , __JI-._I It L._._I. ° _..J 1'._.(__II_.__I'_..} CONVERSION BURNER L.---.I _._J:...231:1:11L1,113 .11:731,17a_,_.J -__J:Si:CI.__._J:ID:- ' _ COOK STOVE ___.),-._:I i• _ i- I.._..J. ,. I_I_.„.4 1.—J.—I____J_-_.J_. DIRECT VENT HEATER i I ___I I p i _ii. . ; _____J -„_._._I ..4_____!`t_-.--J DRYER • ..-J,----3:—.1, I f., I __,_._I!.-...`•__._..l_____.I—J—I'._J__.-,...1:”-....J_..=."».I FIREPLACE ,.—I _ I: J-._I }...J 1•___I___I _11.-1-___J—1-,_ I I FRYOLATOR i----4_J s , ,,_tel' I:__-I._,-,,,_I i...,. .,__J_....,.J'__ J-, .....,._.1-r' _.._.1.,a._.._: FURNACE !_.__J ___._r 1 I''...._.` _,..1;___-1--!1:_ -_J_..! _rj„1._-.1,_..-_' GENERATOR i i; :J _-__. • I I__ `i _ GRILLE I _I;_ ' ' _ -_ _._ ' , I 1 __.2 INFRARED HEATER J I - } t I LABORATORY COCKS ' , ,I ___..i... _J - ._1 i .. ___.. ! J .1 _.._ _ _I _.. I _... MAKEUP AIR UNIT _I• _J I. I I .. I _I _ OVEN _LI. ... POOL HEATER I'—!,� 1 _1�'.�.�_i� t C.—. _I_: , - ROOM I SPACE HEATER • _, ___ _, _1;_____ I L„-I _.__ 4 I___J _....r - ROOFTOP UNIT •; i t'_ , =, I —. ___J • ___:�- .. TEST .__A_I.J_ -�I-,J_,J !.-,-,.1-;----1---7-7- r�f T. ., rte- .. ., . ^r` .. ---r-�� �---' UNIT HEATER '._iI I I . . (I I _-1': J,___1%,„-1 _I•,T 1 w_J UNV WAENTEDROOMHEATER —JrI -0-_-__I -I, I •• I__1__,--J-� - -1--1tb — WATERHE------ _..... ...... _ . J ... Ii NQ . .._I _ I- J - -- J I .. . .......I } 1 I q• ._ i.-_.J __J•__ .J.--. J; - I..._.1,........1 .__J.,____I,.-_.J,..._J �_J.-,.- ,J I---J INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IJ NO U I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY „J OTHER TYPE INDEMNITY „J 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 ..j AGENT i,..l 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 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 comp!! ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 2.72,44c,191.a PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW 1 LICENSE#:12298 I SIGNATURE MP.:-I MGF:,,,_I JP ,,] JGF J LPG! J CORPORATION•I#'3281C I PARTNERSHIP__I# I LLC _,I#. COMPANY NAME: E F WINSLOW PLUMBING&HEATING j ADDRESS•8 REARDON CIRCLE I CITY SOUTH YARMOUTH j STATE i MA F ZIP i 02664 ITEL'508 394 7778 I FAX 48256 CELU N/A ( 50839EMAIL:accountspayabledpefivinslow.com . w� Department ojJnc&sirtalelecsaenvs tmi"±=0 Office of Investigations •, �': _ _ ,# 600 Weshfagten Street '.. 'i.= v Boston,IV 02111 %a;• .' www aintass gov/din ' Workers'Compensation Insurance Affidavit:Da 1lders/Contractors/lElectrlchmaR1®mnbers Applicant Information t� Please Print Legibly .• Name(Business/Organization/Individual): E•F.Wi,n$10. ,..1 Q (V.Joivtej 2• leo. , ) c frit. Address: ' Qeo•dcvl C]4t. City/State/Zip: Schtkcn Vcn 'c,,,k+ t•IPc Phone#: `5(13.399-117V • Are you an employer?Check the appropriate box: Type of project(required): )5:111 am a employer with i0 4. 0 I am a general contractor and I 6. ❑Now construction •employees(full and/or part-time).* have hired the sub-contractors 1.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition " working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its ' required.] . • officers have exercised thew 10.0 Electrical repairs or additions t.❑ I am a homeowner doing all work . right of exemption per MGL 11.0 Plumbing repairs or additions . myself.[No workers'comp. c. 152,§I(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#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 end then hire outside contractors must submit a new affidavit indicating such. ::oonfractors that check this box must attached an additional sheet showing the name of the sub-contractors[tad thelr workers'comp.policy Information. tin an employer that fsproviding workers'compensation insurance for myemployees. Below b the policy ancijob site 1 itormdtion. /� ' ttsuranceCompany Name: Ari()+.} rk iko.A , IJ`ttrU.nCQ- \n tan vetv1y alloy#or Self-ins.Lic.#: Ma I /r `1 Expiration Date: c-1 — a(�1'1 it,Site Address: W Conn/note) 1 y Cid 0111 City/State/Zip: 4)14 457 'tech 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 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 f up to$250.00 a da a ainst the violator, Be advise:t a copy of this statement may be forwarded to the Office of • avestigations the DIA for insurape- .overage ven a on. / do hereby certify un'• e pains an.penalties o pe fury that the information provided above is true and correct. c at!1t 1 Date: (;11311 am? hone#: .SDI-399. 777X Official use only. Do not write In this area,to be completed by city,or town official • ..J City or Town; Permit/License# Issuing Authority(circle one): 1N '\ 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other . Contact Person: Phone#: • \