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Home My WebLink AboutBLDP-19-003289 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM r' —" J _ 1777011 MA DATE II OA / I$ PERMIT# 340/s l9-6b 9R2? ' I.r„ CITY) A JOBSITEADDRESS I)35 C6fDI- &,ren Re) YHA,y I OWNER'S NAME` Kinn Johnson P OWNERADDRESS 561 04 TEL 509160 C R C I FAXI I TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NOM FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ .I _ . :1111111 . CROSS CONNECTION DEVICEI - .__. r DEDICATED SPECIAL WASTE SYSTEM . IMF ; - DEDICATED GASIOIUSAND SYSTEM - DEDICATED GREASE SYSTEM s DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER 1 . DRINKING FOUNTAIN i_ _., . FOOD DISPOSER FLOOR/AREA DRAIN - • INTERCEPTOR INTERIOR KITCHEN SINK v. _ LAVATORY ROOF DRAIN SHOWER STALL SERVICE IMOP SINK I - TOILET l_ -------- - --- -- URINAL WASHING MACHINE CONNECTION -WATERHEATERALLTYPES Dr- - - OTHER f___WATERPIPING _ - - - INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CVO ERAGEBYCHECKINGTHEAPPROPRIATEBOXBELOW ' • LIABILITY INSURANCE POLICY ID 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT. k0 I hereby certify that all of the details and Intonation I have submitted or entered regarding this application areand accurate to the best of my knowledge f and that all plumbing work and installations performed under the permit issued for this application will be In corn Fence with all Pertinent provision of the , Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .dei -/ es 8 PLUMBER'S NAME j STEPHEN A.WINSLOW I LICENSE# 12298 SIGNATURE ^ MPD JP❑ CORPORATIOND# 32810 PARTNERSHIP❑# LLCQ#) I sI S o COMPANY NAMEI EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY I SOUTH YARMOUTH STATE MA r ZIP 02664 TEL 1508-394-7778 1 a ? FAX 508-3944256 CELL N/A EMAIL I accountspayable@efwinslow.com I • if lib G$ 3 ga aVW te.vssssswnrrs.masn J Ara•suuucssssucasu IC.._ Department of Industrial Accidents 1 Bil_ t Office of Investigations t �� 600 Washington Street ` • Boston,MA 02111 1/4a.,, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers plicant Information r /� Please Print Legibly ame(Business/Organization/Individual): E.c.WtnsiOva YttU„ylo L Vito-`.,l Qej int. ddress: g Getty, C'ataQ- ity/State/Zip: Sc s in `fcn,•aa„k•n, l Phone#: 'OS-399-177St re you an employer?Check the appropriate box: Type of project(required): am a employer with 70 4. 0 I am a general contractor and I 6. ❑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.; 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 II 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 insurancerequ red]t employees.[No workers' comp.insurance required.] 13.0 Other applicant that checks box to must also fill out the section below showing their workers'compensation policy information. • Leowners 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 'nation. /� � 1 ance Company Name: (ryd�,J r%iht0A Inrexa n Ct.. Cfswyboi y#or Self-ins.Lic.#: 'i$a 1 A • Expiration Date: I—I — ao9 ite Address: 3 C/varvwx.1w•ea_141-, A4- .0 Ctey110j. ATA City/State/Zip: 4ma)4b7 it a copy of the workers'compensation policy declaration page(3howing 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$250.00 a da a ainst the violator. Be advised ti.t a copy of this statement may be forwarded to the Office of :igations the DIA or insure, - overage veri ar on. ereby certify un • penalties o p•jury that the information provided above is true and correct. `.T. Date: la i aol' #: co% 3 l`1. 7 7$ cJ! ?dal use only. Do not write in this area,to be completed by city,or town official • ea`� • y or Town: • Permit/License# I t1 ring Authority(circle one): board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing )they Inspector '� itact Person: • Phone#: i ern `, J tt_7t CITY( Iouriot1H IMA DATE' If/?-4 ] /$ IPERMIT# &Z2'y JOBSITEUUADDRESSII35 AOf DOICOYI Rd prm�u�H IOWNER'SNAMEI V1,/,'//notJOinn5an G OWITET((tIDDRESS I lrq/71? TB'50$760 616 I IFAX[ TYPE OR OCCUPANCY TYPE COMMERCIALQ EDUCATIONAL RESIDENTIAL PRINT CLEARLY NERD RENOVATION:❑ REPLACEMENT:( PLANS SUBMITTED: YESQ NOD APPLIANCES? FLOORS–r BSM 1 2 3 ft} 5 6 7 8 ' 9 f 10 j_ 11 ' 12 13 14 BOILER �,I� BOOSTER – � �� CONVERSION BURNER =11.1 1111.1 COOK STOVE --- = DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER, LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM SPACE HEATER ROOF TOP UNIT TEST . UNIT HEATER r r UNVENTED ROOM HEATER - WATER r . OTHER _ _ _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑, NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE INDEMNITY El BOND Q OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT Q SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true accurate to the best of my knowledge end that all plumbing work end Installations performed under the permit Issued for this application will be In compli with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. p r /� q� PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE 12298 /`fSIIGNATTUREE •41C— Ate a a— MPD MGFD JP D JGFQ LPGID CORPORATIOND43281C IPARTNERSHIPD4. ILLC❑#I • I 0 o COMPANY NAME'EF WINSLOW PLUMBING&HEATING I ADDRESS'8 REARDON CIRCLE -71 cr- CITY SOUTH YARMOUTH I STATE MA ZIPI 02664 ITEL I 508-394-7778 FAX 508.394-8256 CELLI N/A IEMAILI accountspayable ,efwinslow,com 1 p$}A aIOC. yV0I6II WI61 I4146606 iv I IZP0.,JYganCIOiflJ Department In l I �t p menP of dastrial Accidents ' • .�I_ ^ Office of Investigations t_..d1_ • 600 Washington Street fjl Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers 'leant Information Please Print Le r ibl tme(Business/Organ zation/Individual); E.C.µri �ow (10.0,10- . g all . e. ft idress: ; i •odtvl .. r 2. r ty/State/Zip: as 0- yln N Phone#: 'SW-391-177C1 you an employer?Check the appropriate box: rramemployer with 70 4. 0 I am a general contractor and I a empType of project(required): ' employees(full and/orpart-time).• have hired the sub-contractors 6' New construction 1 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. [No workers'comp.insurance 5. 0 We are a corporation and its - 1 0.❑Electrical repairs or additions Building addition required.] officers have exercised their. 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 required.]t employees. 12.0 Roof repairs [No workers comp.insurance required.] 13.0 Other wlicant that checks box RI must also fill out the section below showing their workers'compensation policy information. owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating puch. ctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. teflon. employer that is providing workers'compensation insurance for my employees. Below is the policy and job site ace Company Name: j t s[.„y f-{u hjeA #or Self-ins.Lica.#: J$a I /� �,,,,_uw- Expiration Date: (—[— a109 eAddress: (avow, 6-1 Ccs s set la�� NI City/State/Zip: O,34to7 t a copy of the workers'compensation policy declaration page('showing the policy number and expiration date). to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a • 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 r$250.00 a da a:ainst the violator. Be advised t..t a copy of this statement may be forwarded to the Office of gation • the DIAfor insure, - overage veru on. reby certify a penalties o I• u �J ry that the information provided above is true and correct. is ..- .41 ' . '_ Date: I . i ami- i• 1 .777; tial use only. Do not write in this area,to be completed by city,or town official or Town: , Permit/License# ng Authority(circle one): lard ofHealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Ler '• ��i f\ '+ act Person: `�\ \\ - �J� \ Phone#: ,0 QI