The URL can be used to link to this page

Home My WebLink AboutBLDP-19-001108 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,C ' O G =a g‘viiiisF_� CITY /^/CIST Y,y/�, �,,0T,d._. . MA DATE �r�/P PERMIT# / 7t i- JOBSITE ADDRESS _____ Lr 0 U 1 OWNER'S NAMEV/ifj✓CS/ NE. flYL C I P OWNER ADDRESS Lief 6'X vce 04,9-friste rrh$' I Tal 779 teal D 7ZIJFAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q RESIDENTIAL gJ PRINT CLEARLY NEW:Q RENOVATION:Q REPLACEMENT:0 PLANS SUBMITTED: YES Q NO0 FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB – – I i ,1' X I - I - 1. I t� CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM I I I „. 171 I I I DEDICATED GAS/OIL/SAND SYSTEM t'' x I'. 1_ ---1- - - 'I Y – t " DEDICATED GREASE SYSTEM 1 I ` ` DEDICATED GRAY WATER SYSTEM – Ir _ I ! •'I _ 1_•.. 1 DEDICATED WATER RECYCLE SYSTEM I- ' DISHWASHER DRINKING FOUNTAIN / 1 --I( I . - I I Y 0ODISPOSER �— ( _I D FLOOR 1 AREA DRAIN INTERCEPTOR(INTERIOR) i — I--1--` _ - KITCHEN SINK LAVATORY 'lltia��ii 0 �MI ROOF DRAIN SHOWER STALL ' 4-4 I ' '1111 TOILET URINAL amoriallaMISSINIMOINIMIESIONS1111111j PIPINGWASHING MACHINE CONNECTION 111111111111-1111 `eon WATER OTHER i , IIIM la ' l'1 .1 ' ' in ' MIN ikk I I I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[J NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY Q 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 Q AGENT Q SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application a a e 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 [glance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • / , PLUMBERS / NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP[✓] JP ID CORPORATION Or # 3281C PARTNERSHIP 0# , LLCD# COMPANY NAME E F WINSLOW _ ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA A ZIP 02664 1 TEL 508 394 7778 FAX 508 394 8256 CELL EMAIL ACCOUNTSPAYABLEtEFWISNLOW.COM w— Department ofdndt:strtinacctaenrs 4 ;hit^•••• Office of Investigations I:. m= s 600 Washington Street ' ' =i'`{`{- '" Boston,AS 02111 • Yea:•..0". www.tnasi.govidia • Workers' Compensation Insurance Affidavit;Builders/Contractors/Electricians/Plumbers Applicant Information r� ` Please Print Lettibly .• Name(Business/Organization/Individual): E.F•WTird1OW kitaittOier.t &L1co.t,1 `m) Gorky, Ifit. Address: 3 �) eitr].2- Q - City/StateiZip: Sos kir NPc Phone#: `SOE-3991111Si -- Are you an employer?Check the appropriate box: Type of project(required): ,,.I am a employer with 10 4. ❑I am a general contractor and -6. L. New construction_ .employees(full and/or part-time)* have hired the sub-contractors i.❑ 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. 0 Building addition [No workers'comp.insurance 5. ❑ We are a corporation end its 10.0 Electrical repairs or additions • required.] . • officers have exercised their 1.❑ I am a homeowner doing all work . right of exemption per MGL 11.0 Plumbing repairs or additions . myself[No workers'camp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required]t employees.[No workers' i3 ❑Other comp.insurance required.) thy applicant that checks Irak HI must also fill out the section below showing theirworkers'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. :oontractop that checkthis box must attached an additional sheet showing the name of the sub-contractorsq,id their workers'camp.policy information. tm an employer that is providing workers'compensation insurance for niy employees. Below is the policy andfob site ` formation. //�� •• f ,i tsurance Company Name: A�--el)+,) ' Cka 601 .rn,l' tr-4.et 62- r ay alley#or Self ins.Lie.#: 1 B a I A Expiration Date: (—1 — aOV1 Ib Site Addressa3 Cn.vvvkanw•ee-1(-h A-04) C4`eSW\' M City/State/Zip: Dayto7 .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$250.00 a da a:ainst the violator. Be advised t at a copy of this statement may be forwarded to the Office of • tvestigatians • the DIA for insure? 'overage wen a on t do hereby certifis tin,e e airs an,penalties o pe,fury that the information provided above is true and correct. ianat&et` A Date: t,`L)31 I a0 k 5 hone#: ,cbi•r 1/41, 77g Official use only. Do not write in tuts 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#: ---_,......z.,\, MASSACHUSETTS UNIFORM'APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK fg._LI CITY '& st,,H Tie IMA DATE ,p: o -/D' EPERMIT#frpf/9.417IIaD JOBSITE ADDRESS: ::>....51.• .�J'Lt/LJt�•/ Ja L' n/utI OWNER'S NAME' 47,9;/e y )'✓J G,fh'fl • •i G OWNER ADDRESS •. t} q{ //`i6 1 f f XN e ?TEL tRif d5 5• 1,FAX,' TYPE OTR OCCUPANCY TYPE COMMERCIAL.__ EDUCATIONAL D RESIDENTIAL 4 CLEARLY NEW:'., RENOVATION:.) REPLACEMENT: , i PLANS SUBMITTED: YES JJ NO ill APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 8 7 8 9 10 11 1 12 13 14 BOILER (_._I7.!! 1_.-7_....-3-777:-rII ( - -i__. I 1 BOOSTERh:_._-i.�•� 1'__._.I._.._I�---�,....- �. .1,_..._.}..._.1�.�.....C-1i_.__�...... � CONVERSION BURNER 1._. .J 1- -1-" 1;-"7"--..)=1:111 .-_J.�-1 ...'.J•. ._1._ 3 1.._..; COOK STOVE I .n_f_ ._I.__j -_.,J,._._J___!-,__._I ____I.._,..,J:_..e..f__....1...._4,..,. DIRECT VENT HEATER I_J'_,.411_ —Ji•_„ i_, � _—• (• - j DRYER m1--I -?:-_...J-.......1:. _.I--I! t_._I ..i,J t J'.�.,1.�4�,�.I_ . FIREPLACE .x-..4 J,__.--1__Y ,�1._.4I:._.-._l--n-ai �-=.--i',r-I FRYOLATOR i=t �, ,�_1__.I._1; •._,.,__i_1:--1-1.�...J- ': --' - FURNACE RATOR z:ACE _a'_.`.`,!---.4.i. ._I--'-1.--x i�774,/i'-- -1T. 1- —•--i-r...NJi - —I Ern-I .. GRILLE ',-m--1—no- -s--J 1,1--_J, --i�----1 INFRARED HEATER �srf--2 J-.n„J „rJ_rarl-..•.4AP-J--.j�. .-1 _J,..,_R r i�, LABORATORYCOCKS l_ __!: ..__.I I -�__ ..__.. I . _. MAKEUP AIR UNIT i —1 --_I I'-- t_-_ ' ..J.... _'. _..._l.--J I _ OVEN i i I• ___J' . _- I___- ! I. __LI_ __! POOL HEATER _____I: I _.. _� _ I ROOM!SPACE HEATER ( J __11 •I�I ROOF TOP UNIT (—f I i i'-1 ^} ,-�- `_.�-..:c (�, _i`rte'__J tai ___i,.____i_____.!_--�I^-r) TEST • __J___,_.1-._J—i__.J_J.�1.._,�J�I___J 7...1` . I_.,:.1 i,.._,J UNIT HEATER L ' ' I '__,]-Jirt_1�' —+_..J_Fri _ITS ___J UNVENTED ROOM HEATER TT1:" ' V--:-21-T-1:--- 1 - - 1 WATER F,A . _ �. ........ __. _ � i J-. .. .l. I- � i� i ...:11—i__ .,_._J b (. __ ',____.__ _._I qj OTHrR:.._....._ .: -._.._ .- . . -.F_�_1 ._. I.....-1, 1 - ...1c -J-1`_1_I J_ J _t_-1 Gr 1.____] '. ..I -_i :11:1:1::::i-1'_ •-i---1_-.J 1i:1_1 1 I.:3 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IsI NO Li 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 �_,j OWNER'S INSURANCE WAIVER:lam 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..) 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 d accurate to the best of my knowledge end that all plumbing wodc and Installations performed under the permit Issued for this application will be In compile e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Oi...,— _______ PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW _ . 1 LICENSE#.12298 SIGNATURE MP. MGF.L,I JP „j JGF J•,_j LPG!J CORPORATION•+]#i 3281C 'PARTNERSHIP.;_1#,,_, LLC .J#. COMPANY NAME: E F WINSLOW PLUMBING&HEATING _ I ADDRESS 8 REARDON CIRCLE t CITY SOUTH YARMOUTH j STATE I MA {ZIP i 02664 ]TEL'508 394 7778 FAX:508 394 8256 I CELL.:N/A (EMAIL accounisLaXable@efwinslow.com iE40b Ila Department ofIrarsestrsaahnccsaenrs .c . 1=fit' Office •oflnvesftgntdons u Y ,,,�`_y,, 600 Washington Street Boston,I' 02111 • ``2••;,>' t.rnassgov/dila ' Workers'Contpemsatiom ! aurance Affidavit:Bnllders/Condrnctors/]Electrieisms/Pknbers Atntallcant Information 1 ' /� ` • Please Print Legibly- .• Name(Bustnesslortgianization/Individual): E•F.1MiAS1QUO 0Q1,40iet3 L aeo_\. Q, cin felt. Address: 3 KPottinn C.draga- . (J 0 _ City/State/Zip: Soo kit 'ciw.a.Arin NPr Phone#: 508-399-1'17 . • Are you an employer?Check the appropriate box: Type of project(required): ,, I am a employer with 10 4. ❑ I am a general contractor andI 6. ❑New construction .employees(full and/or part-time).* ----- - have hired the sub-contractors - -..- - - - -- I.❑ 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.insunnce. 9. 0 Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its • required.] officers have exercised their 10.❑Electrical repairs or additions 1.0 I am ahomeowner doing all work . right of exemption per MGL 11.0 Plumbing repairs or additions . • myself(No workers'comp. a. 152,§1(4),and we have no 12.0 Roof repairs . • •, insurance required.]t employees.[No workers' 13.0 Other comp.Insurance required.] lnyapplicant that checks lc&fImustalsotilloutthesectionbelowshowingtheirworkers'compensationpolicyInformation Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit Indicating such. :oontractonthat chec(cthis box must attached an additional sheet showing the name of the sub-contractors and their workers'camp.policy Information. tm an employer that is providing workers'compensation Insurance for my employees., Below is the policy and job site llrormdtion /� - r d ac=woreCompanyName: l�1CY0+,-1 rkk)t•thaA nfluuncz \ ta,..p. y • olicy#or Self-ins.Lio.#: 1 S a I Pv '1 Expiration Date: CH - 7 o1"? • )b SiteAddress:a3 CmtwvitrW n Po-lrs1 Jolla/ Ce�AAV Yh7C City/State/Zip: Oa LI 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 o.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 hip to$250.00 a da a St the violator. Be advised t,.t a copy of this statement may be forwarded to the Office of • tvestigations . •DIA for insurape= •.verago veri a'on. t . -.i. do hereby corgi un sr• v ,• • r penalties o jury that the Information provided above is true and correct. Et I / S rate• b. I ao[b" hone#: .SU1l•35y• 777X • \s-,: ! Official use only. Do not write In this area,to be completed by city,or town ofJicfaL • City or Town; Permit/Lleense# I ` Issuing Authority(circle one): . 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other * t Contact Person: Phone#: I