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HomeMy WebLinkAboutBLDP-19-001929 40 \184C115 • OFC iiallAirstik 1°40- r'V ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Itr tee • PERMIT#��n.� nom= --Q77� g =T^'1- CITY c.r l L.\U1 VUY1N �1 IMA DATE OM ANI J08SITEADDRESS��akila NEL ��.4 i MEEMICID , \iI �• & OWNER ADDRESS Itfrr� T "' TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL® RESIDENTIAL\ PRINTPLANS SUBMITTED: YES® NO +� ' CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: FIXTURES I FLOOR-+ 0000nn0Ufln1ntanmas OnitillitalialiteSTSMITSTitm CROSS CONNECTION DEVICE Wi(( 1) illitalealinilltSWITSWALIWN DEDICATED SPECIAL WASTE SYSTEM S � .- ' DEDICATED GAS1011ISAND SYSTEM .a _l1 'n '. DEDICATED GREASE SYSTEM i 'SISMI DEDICATED GRAY WATER SYSTEM I�JJ1MISJ SES- i ' DEDICATEDWATERRECYCLESYSTEM a� e DISHWASHER MS1MI DRINKING FOUNTAINFOOD DISPOSER .POS tAMMISSISCS SSIPINAMNS FLOOR!AREA DRAIN MASTIONO INTERCEPTOR INTERIOR ei MOSINISORNOSISSIONSPIONS tiintiONSWIfilittinalatiOntli RYtill- J l ROOF DRAIN Stil11 a SHOLL 1.I ai ISSO SERVICE/MOP SINK SSLSS IIMEntinglallin , OLET arelialirterlitailiatlaSIMINISSIS WASHING MACHINE CONNECTION l _� nIae vansoursi EitiTi llikatailMailairilillitinaliMIPOSSISMil OTHER *Oee1110310.100 ntairl. iiiilliggilliliiii*Onalilrellite r INSURANCE COVERAGE: 1 have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES O NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW , r - LIABILITY O OTHER TYPE OF INDEMNITY 0 BOND U OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement AGENT CHECK ONE ONLY: OWNER • SIGNATURE OF OWNER OR AGENT nd and that all pluthat all of the mbing work andInstallatlpils and lns performed have under theltted or entered permit Issued for this applicarding atios npwill be In•••anceawith all Pertinent provision of theedge Massachusetts State Plumbing Code and Chapter 142 of the General taws. ASN/ _ "__, /, PLUMBERS NAME'STEPHEN A,WINSLOW 'LICENSE# 12298 SIGNATURE MPO JPO CORPORATIONO# 3281C -_ PARTNERSHIP®#Inilla,LLC®#IL:D COMPANY NAME EFWINSLOWPLUMBING&HEATING IADDRESS 8 REARDON CIRCLE ' in CITY SOUTH YARMOUTH STATE MA ZIP 02664. - TEL 5.08-394-7778_ i winslow.com- -- FAX 508x94-8256 CELL BIM EMAIL accounts:a able 0ef- _ �,//� / f' LGr, r . : . . I ' The Commonwealth o 1 f;>he t D frialAc Accidents _n411 Department oflndusirialAccidenfs . crlif �' I Congress Street,Suite 100 .�t� Boston,124 02114-2017 Workers' www.mass.gov/dia Compensation Insurance Affidavit:General Businesses, AA IlieantInf0 TO BB FILED p/ THEPERhdpI7II GAUTgpg1TY • rmation Business/Organization Name:E.F.WINSLOW PLUMBING&HEATING CO„INC Please Print T e 'bl • Address;8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664, phone#:508-394.7778 Are you an employer?Check the appropriate box: 1.0 I am a employer with IQ_employees Business Type(required): or part-time).* •ployees(fulland/ 5. []Refer 2• • ® Iamasole proprietor orpartnershipand have no 6. DResta employees working for me in any cauranNBar/EatagEstable ate, parity, 7. 0 Office and/or Sales(incL real estate,auto,etc.) [No workers'comp,insurance required] 3.❑ We are a corporation and its o 8• 0 Non-profit flcershavaexerosed 9. ❑Enterfannrent their right of exem ption per o.152,§1(4) and we have 4.0no employees.[No workers'comp.insurance require + 10 Health Care ng We are anon-profit organization,staffed by volunteers 11.0 Health with no employees,[No workers'comp.insurance req.) 12.0 Other *Arryepplicentthet checks box#1 r **If dm corporate checks box exemususta sonfyyleout tsthe but the showing their workers'compensation policy • orgenlmconshaeoffiers have ex corporation has other e 10 aYitionpolicy a employees, is re4ulredandsuch an I. Lem an employer a,.,,,.____. insurance Company iRO Workers'compensationinsuranceformyemployees. P yName:ARRWMUTUALINSURANCECOMPANY Sel0Wutlrepollcyfnfarmation. 'morer's Address:23 COMMONWEALTH AVE city/state/zip: CHESTNUT HILL,MA 02467 \ Policy#or Self-ins,Lk.#1821A [�F Attach acopy oftheworkers'compensation policy declatationpage(shownExpi Done ll i' Failure to secure coverage as re gthe p olio Date:number and expiration fie quired under Section 25A of MGL c.152 can leadto the' ynumbef and na penalties of a fiup to$1,5(10,110 and/or one-year imprisonment,as fine neupo$1,so.00an /of up to$250.00 a day or onthe e-yearmpr,o ent, thlacivil of a STOPWomm�RDERndafi 1iwell as op l penalties tgstatement the form be STOP Won ORDER and a fine Investigations of the DIA for insurance coverage verification.copy ofth s statement may be forwarded to the Office of Ido hereby cera ".' • tenaltleso perfutyMattkennfe:motionprovider1 above tstrue amicorreM, Si_ afore: ' L Date: I *hone•:508-394-7778 • Official use only. Do not write In this area,to be completed b cf c;‘,..,k�Ci arTo Y ryortownofflctal tY wn: \k IssuingAuthortty(circle oaej: Permit/License# 1.Board of Health 2.Building Department 3. 6,Other City/Town Clerk 4.Licensing ' Board 5.Selectmen's Office Conte ctPerson: phone#: www.mess.goyldia 1 vib 481-1q15 $q0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I�Gr ea G - / /��I�'a0�sn2 k1-2 CITY -- PERMIT f Q } JOBSITEADDRESSLi -Ec IF .� nge_jOWNERSNAME , vEGux G LL;am�"; ""L' ----•- ,•�,-�-(} ' I C©[�, OWNERA.DDRESS r..�d It net., QI TEL�la,!-Q3 19.11 �',w.- .. ._.L • TYPE OR OCCUPANCY TYPE COMMERCIAL-1 COMMERCIAL-1 E UCATIONALTi RESIDENTIAL PRINT / CLEARLY NEW::,. RENOVATION:;� REPLACEMEN . ,I' PLANS SUBMITTED: YES w! N0 APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 :10111 12 13 14 BOILER _ _ .. . _ .__. ... _ _ . BOOSTER _ - —.^ _ CONVERSION BURNER T COOK STOVE DIRECT VENT HEATER _^ DRYER , FIREPLACE FRYOLATOR FURNACE _.. GENERATOR —. GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER_ _--,• X 1 OTHER..... s INSURANCE COVERAGE I have a current liability inset ante policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1.1!NO ;..„,-i I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a; OTHER TYPE INDEMNITY _3 BOND L.... 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 -Ti AGENT Li 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 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 ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 -- ' SIGNATURE MPI ., MGF w_I JP._ JGF„ - + LPG' CORPORATION I+ # 3281C �l PARTNERSHIPC. # „_y LLC. , #�y_ } COMPANY NAME: EFWINSLOW PLUMBING& HEATING ADDRESS 8 REARDON CIRCLE- ....._ , - - , ----_—_.w___._-_ CITY SOUTH YARMOUTH ; STATE MA -I ZIP 02664 `TEL'508394/778 FAX 508394-8256 ,CELL N/A EMAIL'accountspayabe@efwinslow.com Sga {,.F VV,,.,.s.#nrrFM..,. J .1..04.0•74••••••••••••61.0 - \ i =_=q Department of Industrial Accidents r. _•;e=')�l_= " Office of Investigations =Ian= y . 600 Washington Street "� `l— y Boston,MA 02111 • a �,0, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly I G •�,�1,,�3I „., (ti>.4�n-tl 0tc- c Name(Business/Organization/Individual): E•-- ts) IOC . Address: '' &eoc(txn C'itrka_ City/State/Zip: Sc,:-.M Yrn''c..4-tn MA- Phone#: `}S- 399-1'7'7 Are you an employer?Check the appropriate box: • Type of project(required): -4I am a employer with 70 ` 4. 0 I am a general contractor and 1 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. ❑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 i.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 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 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. isurance Company Name: n�ft— ,;.; (`(J CL( , k . 11 LVtk el Cit_ C cwsik\•iy olicy#or Self-ins.Lic.#: ( 3 of i Ar Expiration Date: (—[ — ,atii9 ib Site Address:., 3 Cannin rl 1/4,"-ee_141-\ . ) C(..CS.kt14 14;11 City/State/Zip: O,)r-1 67 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure 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 lup to$250.00 a da against the violator. Be advised that a copy of this statement may be forwarded to the Office of tvestigations the DIA for insuragee)overage verifayton. J do hereby certify un e r ns an lI penalties obe jury that the information provided above is true and correct ignatu : �/L r» Date: (D.) 31 I aow hone#: cty 7;99 - 7 77g 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 l( r Contact Person: Phone#: