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Home My WebLink AboutBLDP-16-002912 rr ICS, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • 7,-; CITY(YMA7/7W MA DATE /0 lb•/LC JPERMIT. GAJ/ � -Lt2aQ�Z JOBSITE ADDRESS v , iodgie,,Io,r end .I OWNER'S NAM-ificSlingetra POWNER ADDRESS ``aiSt' 1464e r1 :. . .... '1 TEL FAX 1111.111.111 y TYPE PR NOR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL�7 p. CLEARLY NEW:0 RENOVATION:0 REPLACEMENTar g .-- z 25'7 PLANS SUBMITTED: YES NOEK S1 FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 ' 7 8 9 10 11 12 13 14 tBATHTUB 4 - L I L I A CROSS CONNECTION DEVICE y a I w DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISANDSYSTEM e_ ` , DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM - DEDICATED WATER RECYCLE SYSTEM x» i fz.3 DISHWASHER O DRINKING FOUNTAIN * f FOOD DISPOSER b 9 �j� FLOORIAREA DRAIN _ lk INTERCEPTOR(INTERIOR) }' KITCHEN SINK r ,, # � LAVATORY L d ROOF DRAIN \'• STALL l SERVICE IMOP SINK 1 ik TOILET URINAL . —, WASHING MACHINE CONNECTION // _ ir. - 4 1 WATER HEATER ALL TYPES L _ .. WATER PIPING OTHER r i ! 1 ` k > I I 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[l NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY +❑ 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 a 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 (lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER'S NAME STEPHEN A WINSLOW LICENSE# 12298 /ry SI /NATURE MPD JP CORPORATION Q# 3281C ,PARTNERSHIP❑#... LLC 0# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH 1 STATE - MA ZIP 02664 TEL 508.394-7778 FAX 508-394-8256 CELL EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM The Commonwealth of Massachusetts l�=wi Department of In'flhist tr al Accidents htli_ Office of Investigations E;- _,.t 1= y 1 Congress Street, Suite 100 Boston, MA 02114-2017 "��•° www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly E. F. WINSLOW PLUMBING & HEATING CO.,INC. Name (Business/Organization/Individual): Address:8 REARDON CRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone #:508-394-7778 Are you an employer? Check the appropriate box: Type of project(required): 1.MI am a employer with 70 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 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 for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MOL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic.#:1794 A Expiration Date:01/01/2016 Job Site Address: • City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A'of MOL c. 152 can lead to the imposition of criminal penalties of a fine 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 of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of t IA o • uranc• co erageveri c.tion. Ido hereby certfy un erins and enalties r 'erJury that the information provided above is true and correct Signature: \ Date: 2016 Phone 11: 508-394-777 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 '� Contact Person: Phone#: 'i1 • j MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ®nu• r' „_ hp 4( ;it CITY _ (�1 L000�� • I„MA DATE/O'/w'I5 PERMIT AVP '�0�7 JOBSITEADDRESS: If �� / art 15' OWNER'S NAME 'ji4� M /poly S III M G OWNER ADDRESS I.- `Jbcf Yf'1nniri TN _,.:_ ITELf7 L !q9 vw 'IFAX - . _ . . ,} N% PRINT TYPE OR 4 OCCUPANCY TYPE COMMERCIAL ILI EDUCATIONAL II RESIDENTIAL lie r6 CLEARLY , , NEW:`,LI I RENOVATION:I_„J REPLACEMENT:,,,, PLANS SUBMITTED: YES,,,,I NO;' tAPPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I _.... I I _ �1_.�l �„f...._1 I I _..__I J_ (-_ J BOOSTER I I „_ J 1,_.._.�I _1 _._..1 ( __1 -. wl CONVERSION BURNER r __ I . -...- _.J ___I____I ,__I -_.I .__,.J _...__1--.-.1.___1 _,__I NJ COOK STOVE __ I ..._ I t . . I____ I__J _J .__1 ' -_J ,1 I I. DIRECT VENT HEATER —_i _1 I I I _____1 I __-_.-1 ___J I,_J —I ._J', I J ,- DRYER ____1 I 1 , I__1 ._1 __J�J J I , I. I _. l p FIREPLACE 7-_I_! 1 1 I ..—1 I I I ___=! Q FRYOLATOR I __1 J _LI I_1 I 1 I i I I ____J GENERATOR _J ___J1 TI J ___J I 1 I i 1 GRILLE ____I .I,,._ J __ ____J_J .__I 1 I ___J INFRARED HEATER I I � I� 1 I I 1 I I 1 , LABORATORY COCKS MAKEUP AIR UNIT J-_..- I ___a I _ I;___1 .___I __._I'___-1 .__._I' _J.____i;_.__J ._.__I OVEN -r-__ I ____.I __I.„_1 __J ___J ____I J ___I —J____J .__J ..1 POOL HEATER ,I I ._,_-f I S 1____J 1.___,J , I I_ J-_J ROOM I SPACE HEATER J I . _JI J ___I. I ___J....J I I. J t—I ____I ROOF TOP UNIT ,_,,, ' __,,,,1 _.w.:1 1 _T! _! J. _I I J_..._J I.__I TEST r I J,_ J I !�1 ___i J 1 1, J I I _I - UNIT HEATER I I ____._ I J,__,J __!__..J ___J I __..J_ I _I_ I ' UNVENTED ROOM HEATER .I .J .._._.._! I I -._.! I'..,_I I u__I I_ 1_ II _1 1 . WATER HEATER _i II I___J _.__1.,. _II _2 �._I-! __-J OTHER ,. I ._ J ,,, .1 _u I . ' I ._ I I I____I 1 . .I...._.J I____l ____1_____1 I 1 I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 141 NO I IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY .t J OTHER TYPE INDEMNITY H , BOND I J ;. 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 Li AGENT L.,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 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 compilee with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. l�dr�� , e/? ,t J nt PLUMBER-GASFITTER NAME _STEPHEN A WINSLOW ^_:_ I'LICENSE#' .1 229.8_j / 'SIGNATURE MP :1XMGF.._,1 JP _ JGF 1 LPGI _l CORPORATION _41# 3281C ( PARTNERSHIP _I.# I LLC .J#; ...... .... COMPANY NAME EF.WINSLOW PLUMBING&HEATING' J ADDRESS:8 REARDON CIRCLE 1 CITY SOUTH YARMOUTH YI STATE MA J.ZIP,02664 -_ I TEL 508-394.7778 I FAX'.50&394-8256 I CELLEMAIL ACCOUNTSPAYABLE@EFWINSLOW_COM 46 6 i a- fr The Commonwealth of Massachusetts _—=—_ l Departthet3t o Industrial Accidents a'.(To_ Office of Investigations _` E1 f—�; 1 Congress Street, Suite 100 Boston,MA 02114-2017 . www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly • Name(easiness/organizatioafindividuai): E. F. WINSLOW PLUMBING & HEATING CO.,INC. Address:8 REARDON CRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone #:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 70 4. 0 I am a general contractor and I employees(MI and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ' 7. 0 Remodeling ship and have no employees These sub-contractors have g, 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insunce.t 9. ❑Building addition ra required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box MI must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContmctors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins. Lia#:1794 A Expiration Date:01/01/2016 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 of up to$250.00 a day against the violator. Be advised t'tat a copy of this statement may be forwarded to the Office of Investigations of A o ' uranc, co erage veil tion. I do herebycerti,un a ins and enalties erjury that the information provided above is true and correct Signature: \ Date: 2016 Phone#: 508-394-777 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 Contact Person: "ea% '%'hone#: