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Home My WebLink AboutBLDP-19-000242 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK de ig. M _ C CITY . __y'j .' s' MA DATE?ff�_!t ..J PERMIT# > C/! ' ' • JOBSITE ADDRESS L)ZJj, lL c!j) C [,t: _ OWNER'S NAME rat . P OWNER ADDRESS L S! Y6 TELSJp �j6�pa FAXL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL El RESIDENTIALg] PRINT CLEARLY NEW:0 RENOVATION:[ REPLACEMENT: PLANS SUBMITTED: YES ] NOD FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB all111.1111111MISMINSIIINIIIIINIM MISIMIN11111 CROSS CONNECTION DEVICE visinisvasinsiiiiiiiransmanismonsimn DEDICATED SPECIAL WASTE SYSTEM IT — 111111111111111 DEDICATED GASIOIL/SAND SYSTEM I ® � I DEDICATED GREASE SYSTEM mg mintsaigismaistssisminallin111 DEDICATED GRAY WATER SYSTEM S�pf11111Iflf.11111111111111�t®fIS DEDICATED WATER RECYCLE SYSTEM isigniminingmituninsuastaillni DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER 1111111131111311111111111111.111 _®® 11111111 FLOOR IAREA DRAIN � ®� � � �� INTERCEPTOR INTERIORIIIMIIIIIIIIIIIIIIIIIIIIININI111111111111�11111®11•1111.1111111 KITCHEN SINK ISSIIIIIIIIIMOISIBIONNIIIIIINNINNINININIIMEINIBSII . LAVATORY ROOF DRAIN 11111111111111111®.111111111111®®11111111__ __ � SHOWER STALL ��® ®�� ®11111M1111111® SERVICE/MOP SINK TOILET URINAL 1111111111111111111111111111111111111111111111111111111111SMNIMIMENIIIIMINI WASHING MACHINE CONNECTION 11111111111111111110111111111111111111.1111111111____ WATER HEATER ALL TYPES WATER PIPING OTHERIIIIIIIIIIIMINI111111111111101111111�� ---------I I--'S ...1111111111111111111.1111111111111111111111111111111111111111111101111111111111111111111111111 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES(+J NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POLICY Ei OTHER TYPE OF INDEMNITY 0 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 E AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that ell of the details and information I have submitted or entered regarding this application ar ue 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 c pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. D ,LGrer ,i PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 . IGNATURE MPID JP❑ CORPORATION CD# W C- PARTNERSHIPD#L_ JLLCD#f... _ .. J COMPANY NAME E F WINSLOW yy ADDRESS I 8 REARDON CIRCLE CITY ISOUTH YARMOUTH JSTATEMA ZIP 02664 —1 TEL 508 394 7778 , FAX 394 8256.CELL I EMAIL ELCSDLIN2SLAXABLEILFWISNLOW.COM 1 • t -T 1lDr;;radmen:ofliaan trlatAwesdemme Office of Iiavestigctdoies •" 600 Praidin ton Street .„--..43, Boston,2/124 02111 • . ,,Lmc www.mtrssgovlttts ' Workers'Compensation Insurance Afffldattit:E>taiklens/Contraotxo>rsfEleetiieie ns/&'Ilombers Applicant Information Please Print I eglblx . • Name(Business&Organlzationtlndividuel): E.c.WIASIOW CAVo.n61,nc) tie.o<4s". (i� Ifit. Address: 3' 4o•ctni1 C)rrtt. - Q City/State/Zip: Soo In ' crwc%,�ln MPc phone#: `50§-3c19r117V • Are you an employer?Check the appropriate box: Type of project(required): ,,kI am a employer with 10 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,: 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 ere a corporation and its 10.0 Electrical repairs or additions required] •,• officers have exercised their 1.0 I am ahomeowner 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' comp.insurance required.] 13.0 Other thy applicant that checks boxfl must also rill out the section below showing theirworicers'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. lonttactors that checlethis box must attached an additional sheet showing the name ofthe subcontractors gadtheir workers'camp.policy Information. Am an employer that isproviding workers'compensation insurance for My employees. Below is the policy and Job site 1 rormrttion. /� isuranceCompany Name: AY— ••,.J' t(.ikali .nDurana CffbvickviLi olicy#or Self-ins.Lion(.#•`: 12.'W Ac 1 Expiration Date: (-1— aD1'1 )b Site Address:�.1 G nnrw.ail w-ealk /0,-,2 y ae4/1(J1' } II City/State/Zip: 8,)x{t,7 Mach 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 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 f up to$250.00 a da against the violator, Be advised tat a copy of this statement may be forwarded to the Office of �� avestigations the DIA for instua�ne .overage veri ca on. / CNN I do hereby gee un�er ta (tins an;penalties o pe fury that the information provided above Is true and correct. a alu3. —L . j Date• Va. i aotC hone#: .cl)g•3 \i-777X • Official use only. Do not write In this area,to be completed by city or town official City or Town; Permlt/License# Issuing Authority(circle one): ' \c..\ 1 1.Board ofHealth 2,Building Department 3.Cltyftown Clerk 4.Electrical Inspector 5.Plumbing Inspector 0 6.Other . Contact Person: Phone#: N` • I` . � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK TIJF CITY • Y/,�/t;?i7,4 m fl. .07-S 7-. 1 MA DATE /6-/P " {PERMIT#7%Z // C6VPW !OWNER'S NAME _ . 4 9. G ---.. -_-.; OWNER : 3 /J_y„( _ P— - ^ I TEL t yo 3 FAX. I JOBSITE ADDRESS:� "Line /St c[c TYPE OR OCCUPANCY TYPE COMMERCIAL; EDUCATIONAL J RESIDENTIAL 2( PRINT CLEARLY NEW:11 RENOVATION:,J REPLACEMENT:•A PLANS SUBMITTED: YES LI NO I APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOOSTER ..„_._;.__ _J'__._. I. � .- I,.___.I ___II,_.__C II__,__! .__..' CONVERSION BURNER _._J I..__ L J..... Ii- _. 1 _ I _ I _ I' COOK STOVE I _ Ii ..__.._! I _ .I_ I __I 1.____I_. .J r..l__DIRECT VENT HEATER . T' ._.Ji I' I __...-...!' __..__al __ 1' -2,___I' --.J,--- DRYER ___J_.__I J I ____II____I —l.____J..__.I'.__._JJr! I-_-...' FIREPLACE ----I _I .- FRYOLATOR L____I ,_:• 4 I I I I .,._...;'....__ I___,_I __ _I_i_.1__...-i_,, ,, ..r.....' FURNACE I:___I 2 _ : ___Ji.._. 1 . ..-_--J ._- I,_.__.I I _' GENERATOR J- ! I -. GRILLE ! 1 I ' ' -' ' !_._._ ' I •. INFRARED HEATER t- I __i;...._. _ ._I ._i .._ —I __J _._I LABORATORY COCKS , I .'. ' _ 1 _ J I ' l iI I .. .__I MAKEUP AIR UNIT II j I'_.._ : _ I i i I. -1 r'^ 'sa - OVEN I �._,1I _..- I 1 ! i . ' . _._' _ 1 1 . POOL HEATER 1 Ii'—i ly, '! 1_ I --` ROOM/SPACE HEATER ' 1 _ I I I I I_ I I, —.J -I 1 I ROOF TOP UNIT I t f' I I I _ `.__._J r-1 I , _ - T T UNVENTED ROOM HEATER __� �, t ' I UNIT HEATER __Li I _�LLI _.-! --._._.I - .-J I I _J _.-1 1 1• !. I ��l I I i I J � � l WATERHEATER_. -... / I il_ . OTHER . ... .. ... _ . . ._ 1 i _� 1 II—I_ -1 J fr. I I i I- . J i _ 1 I J. f I J (.N INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1.11 NO '_l 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 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,_•1 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 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. sze PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW J LICENSE# 12298 SIGNATURE / MP _:_i MGF.,,,_I JP it JGF:J LPGI J CORPORATION +}#;3281C 1PARTNERSHIP.:_I# }LLC J#. _ - t COMPANY NAME: E F WINSLOW slyEasisa I ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH J STATE i MA I ZIP i 02664 }TEL'508 394 7778 ..1 FAX'508 394 8256 I CELL N/A IEMAIL accountspayable aOefwinslow.com (A6L `i° LV eco= r Department of lndustrtaiAcetaenes = iXtli= ' Office of Investigations Spat== ' 600 Washington Street =l_�=f'' Boston,MI 02111 • '`'•:.,.'' www.rnass.gov/iiia ' Workers'Compensation Insurance Affidavit:builders/Contractors/Electricians/Plumbers Applicant Information , 1 r� Please Print Legibly .• Name(Business/orgnanizatlonflndividual): E.c.Wsn${0W ` tioAoi L 1CGA- cm} I✓lt• Address: Z' (6 pawl Ca r1P— Ci '/State/Zip: So,kh Yen,,.41n NA Phone#: "OS•3a`1pitir' • Are you an employer?Check the appropriate box: Type of project(required): ,,fI 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 :.❑ 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. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and Its • requred] officers have exercised their 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,§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 bdx#1 must also till 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 anew affidavit indicating such ' :oontracton that check this box must attached an additional sheet showing the name of the sub•contractana id their workers'camp.policy Information. tm an employer that is providing workers'compensation Insurance for my employees. Below is the policy andfob site rormdtion. /� - n • tsuranceCompany Name: Ar1k��o.A1 I w c&nc2 \ pt tvv-, alloy#or Self-ins.Lie.#: I$aI A Expiration Date: C-1 — ani-► )b SiteAddress:,l3 Cnn„t.,anw•ea-11-h Ad-a) CFd& ' 11111 City/State/Zip: Oa LI id? .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 cm 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 advised t t a copy of this statement may be forwarded to the Office of • Instigations the DIA for insuratne overage veri Jon, t do hereby certij,un.• e ens an penalties o pe Jury that the Information provided above Is true and correct. (N ianatu4es--_ .4. Date: (1.)31 ) a01 C hone#: .51)'1.35`1. 777g Official use only. Do not write in this area,to be completed by city,or town official • City or Town: Permit/License# \213 Is1. uing Board o fHeaty(circle one): _ 1.Boardofliealth 2.Bu11d[ngDepartment 3.Cltytrown Clerk 4.ElectrIcal Inspector S.Plumbing Inspector 6.Other . 9:...il. Contact Person: Phone#: •