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HomeMy WebLinkAboutBLDP-19-003409 coxae MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Eigazzeata,j MA DATE la-/F1 PERMIT# n Cd 3 dV JOBSITEADDRESS I ZZ2 %,g e9 /cteagt-' OWNER'S NAMEI T rt/fs /n 1 rfI .. P OWNER ADDRESS _�4 7t1 E TEL[gp�'39Y/7T.,1[FAX[, TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL • PRINT CLEARLY NEW:D RENOVATION:D REPLACEMENT: PLANS SUBMITTED: YES 0 NOD FIXTURES 1. FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ala�filinillitelacitirMINSI DEDICATED GAS/OIL/SAND SYSTEM I INIMSKIIIS®NWIAMMIMIaIMINNIRMIN DEDICATED GREASE SYSTEM MainilialLINIONMENINS111111allallaNiALIN DEDICATED GRAY WATER SYSTEM MiligletainlinSMINitinillintnineralin DEDICATED WATER RECYCLE SYSTEM MINSMSAa DISHWASHERflaaar DRINKING FOUNTAIN ��� FOOD DISPOSER 11.1.1011.111.11161.11111.111,111010411.111S11.01011.11.11S FLOOR I AREA DRAINsisf INTERCEPTOR INTERIOR KITCHEN SINK MOM 511.111ail ssess —s LAVATORY ROOF DRAIN * 5555555555555 SHOWER STALL 5555556 assis SERVICE pa I MOP SINK �� � WANANSITO TOILET �Ii `� URINAL s5111111011111111110111111111111 WASHING MACHINE CONNECTION 01111111.0.1111111.111110.31111111011110111111.14.110.111121 WATER HEATER ALL TYPES WATER PIPING 5nanswsaus R1 OTHER issismtnammtinenssisomusisommairsanansig SMENIMINNIIIIIIIIIII101111111111111111111111111.111MANNITIMINMOMMOS MIN �Iil�li��11 �11fl��lA��lll��[17�11G1i111 INSURANCE COVERAGE: I have a current'lability 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 • LIABILITY INSURANCE POLICY D+ OTHER TYPE OF INDEMNITY 0 BOND D 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.D SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are 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 co ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /eLGs seegiec PLUMBER'S NAME[STEPHEN A.WINSLOW 1 LICENSE# 12298 , - GNATURE MPRI JPD CORPORATION 0 ttlaiPARTNERSHIP[,I#t COMPANY NAME j ADDRESS 1.8 REARDON CIRCLE CITY[SOUTH YARMOUTH 1 STATE MA ZIP 02664 TEL 508 394 7778 FAX 508 394 8256 . 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Ghat s.1o1oszluo3-gns.emu soo&oldwaouvial pm;digs . 2ugapom2ao 1 :loglispagouguQvuopan -taulzedzozo;azdozdKos uvas 1a szo;oexluoo-gne oq;pexpl mug 4,(sutg pedxolpuuling)eaoholdwa' uogDngsaoo maN D •g IP=xoPlaluooplzaua2 a ate I 0 'b it taw xasoldwau mu Ltv • :(paxlnbax);Da[oxdEo egg, sot a;uladoxdds ay.neap yxasoidwa un not ars • MUahbc,1.05e. :#Quota 114 vki1 ` V1r°S :drl/a3BIS/A113 • Litt (1 plc F.J tAsrpod' $ :ssozppd 'yI (03 'b�nal•�'J�7 Iwnecw�ll,) moisvtitt�•3.3 :(IunpinlPul/uopuzyu8xolssaulsng);M • •• 4IPfl;uY•za esBaiaII 1 U uorpnoutopel}ifluonida t ®sa 1F2113/s"isi4sa1E/sBoaoos 003/ssaiep'a agg44Telisel `, ®yuatinugeinem suadmoa asaaxgzo& • ark/402FaU tiMai ., • TIIZOY1 aaeoasog ,_=1 las• g ssog$agalsTlj 009 S''_'�'• salapaal/saaaugfo Rib i =1 e saszaataaaiwsa8dlssaloadF.i®paaaacevas�cia® —'sem MASSACHUSETTS UNIFORM•APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK T.----L—tri • "NUE a" CITY : Soo iMA DATE Ii-yo-6P- (PERMIT#1/ fvr� ✓ r JOBSITE ADDRESS:J 7 7. :Tj/:r2-i✓l�. Ve-wje L' {OWNER'S NAME p kr- (yi�(gly ! GOWNER ADDRESS I. Sd lL1/ ITEL5Q ,i2ye11.2FAxt r TYPE OR OCCUPANCY TYPE COMMERCIAL Fe.] EDUCATIONAL, RESIDENTIAL PRINT CLEARLY NEW:11,1 RENOVATION:U REPLACEMENT:4 PLANS SUBMITTED: YES•_•( NO,.J APPLIANCES 1 FLOORS- 1010©©0© 6 0 8 0 10 0®®1131 BOILER MIAMINMEMANNWOMISSISPOMWASSISPIN BOOSTEROSIMWAMMIIIMMINSISalialtit CONVERSION BURNER NIONSINSIMMISSMANININESISSWOMNII COOK STOVE a IIM MIr SINSI DIRECT VENT HEATER IlitaatIMAINSEEMINISMNIMMINalantila DRYER MIiNINSNIMi FIREPLACE anleallatinalagNIWISIMIXIMMINME FRYOLATOR arnellitlitiliSPENNINIMINSIMIIIMPICONSIE FURNACE _SSJ1___saS__ SINI _ ' GENERATOR 1101.11.11011_111011111111.01/INSPIIIIISIPPINNSI toismossamissalanatenammisassi INFRARED HEATERISIMAaisiIE LABORATORY COCKS '` ailUMNIIIIIIMOSSOINUMIIIIIMIS MAKEUP AIR UNIT Malit1011111111.10S. IINIIIIISPOWEIMPOIMINIMIS OVEN SiSSSMI POOL HEATER iMWSMMPINI ROOMISPACEHEATERa ]ONSSMPSI ROOF TOP UNIT PAPIIIIIIIIIMMIIMPOSISMNIIIIMEMISIMINPII TESTSPIESSSSSSIllinSJSnal UNIT HEATERINEWiSSallI®WIESSIMM®MI® Na UNVENTOIHER WATEREEAT€R�D ROOM HEATER Isstesswasiat®�a—��®ms WinaMINISMINIMINSIIIMIWRISIMISIESIAM • INSURANCE COVERAGE I have a currentliability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [LI NO Li 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 D • 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 .J AGENT U 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 and Installations performed under the permit Issued for this application will be In compll a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J .l t."> .0-ter PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW 1 LICENSE# 12298 / SIGNATURE MP. :] MGF J JP JGF ] LPG! j CORPORATION ±]# 3281C (PARTNERSHIP #,�„.1 LLC ,, t COMPANY NAME- EFWINSLOWPLUMBIN &HE GATING I ADDRESS•8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE 1- MA IZIPI02664 }TEL:108-3-94-7/i8 FAX'5083948256 CELL N/A f EMAIL•accounts pakableefwinslow.Com • - 161, . e.-teH a DePar:Meaa8 op'2eaanStri 584ccgtte, g I=E,� , G Office of Investigations eigIll 600 Washington Street � �'� 1'ostoys,Ids 02111 •• • "as' ininaagass.gov/dig • Workers'Compensation Insurance ,u.davit:Buliders/Cmntaaeters/lEleckriehilas/lnlm>ambeaa 1oplicant Information C '1 Please PaintI,egibk .• lame(BusinesslOrganlzafon/individual): a.c.W 1AS10W glo....bwt Z. eaV+d,c m. rtt. • address: 3 aan c'�ir l . •• ' (4t aty/State/Zip: Soskh ' n'- ..fin t-tP Phone#: `SUS-3qy-lien . . • Nre you an employer?Check the appropriate box: Type of project(required): I am a employer with 70 4. 0 I am a general contractor and I 6. 0 New construction employees(fulland/or part-time).* have hired the sub-contractors : 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, 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 ]Iaria homeownerdoingallwork , right of etemption per MGL 11,0 Plumbing repairs or additions • myself.No workers'comp. 0.152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required] y applicant that cheeks box#1 must also Ell out the section below showing their workers'compensation poltoy Information. rmeown&swhosubmltthisaffidavitindicatingtheyaredoingailworkandthenbiteoutsideconhsuch. ' ntfactors that checktltls box must attached an additional sheet showing the name ofihe sub-contractor%agd theirworkem'camp.policy Information. en an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1 brmuion. nn � a ` • uranceCompany Nome: t�YYj)v.s (` utlio-� `nf ,tom {� try t icy#or Self-ins.Lie.ft: 12 a I Pc • Expiration Date: t—-V ani") . :Site AddresO3 Gnnmailw-ectl "h ALM. 04e4Adi, Elis City/State/Zip: O,)54 7 tach a copy of theworkers'compensation policy declaration page(showing the policy number and expiration date). • lure to secure coverage as required under Section 25A of kla 0.152 can lead to the imposition of criminal penalties of a ' . -� e 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 up to$250,00 a da a:ainst the violator, Be advised :at a copy of this statement may be forwarded to the Office of 'estigatlons• the DIA for insurarne: .overage yeti a,on, t b hereby cerffy un. a pains an,penalties o"jury Thai Me information provided above is true and correct ma �At^� sr�,._moi Date: (l- I . bttiA one#: .S1)St-3119. 7778 .. Official useonly. Do not write in this area,to be completed by city,or town official ' City or Town; PennIt/Llcense# \1. Issuing Authority(circle one): W 1.Board of Health 2.Building Department 3.Cltytl'wwn Clerk 4.Electrical Inspector 5.Plumbing Inspector it 6,Other 1 Contact Person: Phone#: •