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BLDP-19-002800 1MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .-, v�j�--74, CITY 1 Y4fMO J FIA 1 MA DATE 1 U RI Ill 1 PERMIT#fiAPP_/?A Ca b0d JOBSITEADDRESS11c Pore.54- fet.(YU,/O rp07f1OWNER'SNAMEI75oYlq Mi77ct 1 POWNER ADDRESS stone TEso 31cogo9 IFAXI I TYPE OR OCCUPANCY TYPE COMMERCIAL ID EDUCATIONAL 0 RESIDENTIAL a/ PRINT CLEARLY NEW:ID RENOVATION:0 REPLACEMENT:Q/ PLANS SUBMITTED: YES 0 N00+ ) FIXTURES 7 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB IIIMIBIIIJIIIIMIIIIIIIII- CROSSCCO NECTIONDL EVIC SYSTEM _�� DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ i DEDICATED WATER RECYCLE SYSTEM is., DISHWASHER DRINKING FOUNTAIN 1 _ . FOOD DISPOSER .i FLOOR IAREA DRAIN Int ^ INTERCEPTOR INTERIOR INK_ - KITCHEN SINK ;55 - LAVATORY ., . liiiallit ROOF IN SSERVICE SINKTALL TOILET _® URINAL SIM WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I _ WATER PIPINGI - — OTHER r - —_ _ ._v MSS INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY p+ 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 © AGENT 0 0SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are tru 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. PLUMBER'S NAME STEPHEN A.WINSLOW I LICENSE# 12298 SIGNATURE MPD JP CORPORATIOND# 3281C PARTNERSHIP©#I ILLCD#I I C rib COMPANY NAME'EF WINSLOW PLUMBING&HEATING ADDRESS!8 REARDON CIRCLE J CITY'SOUTH YARMOUTH STATE MA ZIP 02664 TEL 1508-394-7778 er FAX 508-394-8256 CELL N/A EMAIL accountspayable(gefwlnslow.cam Q • q6 �3 V\ t 1s4 �VntstisV/sl.iWsas•J / SJJM..,.NJI.sl7 ...r• Department of Industrial Accidents 1 ;I' j=41 Office of Investigations r —al— 600 Washington Street ° 'sBoston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers .pplicant Information f 1t,v Please Print Legibly •a (Business/Organization/Individual): E f.Wins'oo me ut. 6t g the- �6 d Ce) I*IC. ddress: 3 .eodan Cady . • ity/State/Zip: Sas `ern>,-tn t.{Pr Phone#: "OS•3(19rrig 4 e you an employer?Check the appropriate box:I am a employer with 70 4. Type of project(required): 0 I am a general contractor and I employees(full and/or part-time).* -have hired the sub-contractors'' 6 ❑New construction ] I am a sole proprietor or partner- listed on the attached sheet.t 7. 9 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. [No workers'comp.insurance 5. 0 We are a corporation and its 9. 0 Building addition required.] officers have exercised their 10.0 Electrical repairs or additions ] 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 insurance re uired. t 12.[]Roof repairs 4 ] employees.[No workers' 13.0 Other comp.insurance required.] applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.eowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. actors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site oration. ance Company Name:, ('{Ghi0 i)f n t (l , rty y#or Self-ins.Lie.#: $al Ar Expiration Date: t—) — aOi9 ite Address:a3 Connmcn W2o-1411 rtva, Ove.,44)4 I U City/State/Zip: 034 6 7 :h a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). e to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a p 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 to$250.00 a da a t ainst the violator. Be advised t..t a copy of this statement may be forwarded to the Office of \ :igations . the DIA or inure. - overage venlig on. t. ereby certify un - e ains a penalties o jury that the information provided above is true and correct. Ilk i Date: l 01 i oto{7f #: SUS:3Ry• 7?7g ?tial use only. Do not write In this area,to be completed by city,or town official. • y or Town: Permit/License# N O N ring Authority(circle one): • board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector )ther ttact Person: Phone#: Ls. _;n= C := 1=s CITY KrM90 ic1, IMA DATE I I I�IW�n`�9'a �PERMIT# 0 JO& EAD RESSI1.5 I-695- GraI-QYafy Ha) tkOIOWNER'S NAME1Ti(1L101 N1.gi ` ci GOWNERADDRESS I co,ryt f ITEI) 3"ISO 9004a IFAXI TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIO RESIDENTIAL PRINT CLEARLY NEW:D RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NOD APPLIANCES 1. FLOORS-I BSM 1 2 3 4 J 5 6 7 9 9 10 1 11 I 12 1 13 14 BOILER BOOSTER _ - CONVERSION BURNER r rierr ' COOK STOVE , DIRECT VENT HEATER - DRYER FIREPLACE FRYOLATOR FURNACE . . GENERATOR . GRILLE INFRARED HEATER. LABORATORY COCKS +++�� MAKEUP AIR UNIT OVEN POOL HEATER ROOM ISPACE HEATER ROOF TOP UNIT TEST - - UNIT HEATER - - - UNVENTED ROOM HEATER - WATER EATER Man _-- OTHER — • _.- - Y INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ElNO❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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 /7 Massachusetts General Laws,and that my signature on this permit application waives this requirement. . `I> CHECK ONE ONLY: OWNER El AGENT CI $ SIGNATURE OF OWNER OR AGENT Le' 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 end installations performed under the permit issued for this application will be In complla 17e with all Pertinen provision of the 5. :Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Adr / r PLUMBER-GASFITTERNAME STEPHEN A.WINSLOW LICENSE# 12298 Pr - ' SIGNATURE rt MPI MGF❑ JP❑ JGF❑ LPGI❑ CORPORATIOND# 3281C PARTNERSHIP❑#I ILLI❑#I • I COMPANY NAME'EF WINSLOW PLUMBING&HEATING I ADDRESS'8 REARDON CIRCLE I „7. CITY I SOUTH YARMOUTH I STATE MA ZIPI 02664 ITELI508.394-7778 I 9— FAX 508.394-8256 CELLI N/A IEMAILI accountspayable@efwinslow.com I • y6 3 Sas\ a 164 tetra I 6I ILy161YLµ6La6 by II10110u1641600yt4g, zwThT_ Department ofIndustrialAccidents _li el Office of Investigations F ite`_ 600 Washington Street _ Boston MA 02111 �`"` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers applicant Information E f Please Print Legibly lame(Business/Organization/Individual): •l••.Wt 'Qyv �U �''/ A. vi<a�'.�+q, est Int .ddress: 8' Godtsn cata� 0 0 ity/State/Zip:�ou yar.•1c,,k.. h1}ir Phone#: 'V-399.1717Q e you an employer?Check the appropriate box: crI am a employer with 70 4. 0 I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers'comp.insurance 5. 0 We are a corporation and its 1 ❑Build ng addition required.] officers have exercised their 0.0Electrical repairs or additions llama homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no insurance required.]t employees.[No workers' 12.0 Roof repairs comp.insurance required.] 13.0 Other applicant that checks box ill must also fill out the section below showing their workers'compensation policy information. ieowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. actors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site mation. ante Company Name: AY113‘..-) t{v11:o..1 _nt to e y#or Self-ins.Lit. I$ .1 pe � `� Expiration Date: (-1 ^ 101 iteAddress: (.4:1u.t ►krea.�}y� nn Che r(. Ill City/State/Zip: D,)4 to? ii a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). :e to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a p 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 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 igations • the DIA for insura, - overage veri j on. e((reby certify un - e gins a penalties o •jury that the information provided above is true and correct. :Lc Date: l Z I 2101' #: crjt314- 7'7X ...............ci c,,, Ycial use only. Do not write in this area,to be completed by city,or town official • • Permit/License# • \N st ling Authority(circle one): • 1 board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector )ther [tact Person: • Phone#: • • a'