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Home My WebLink AboutBLDP-15-003397 VI i sQ\ 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK wa r, ,.l r CITY P/YJf/ / �� ! - IMA DATE /2 U y /� IT# BLIN,-7,,5--co S3?J JOBSITE ADDRESS I P7 Y / ' /,IJ///,/a/41-1lER'S NAMEI H P OWNERADDRESS I ' �� y r1} ! I y 7ELI SD ‘�yt�7D/f IFAx1 I ' ..•. 11� TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATI NAL 0 RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑� PLANS SUBMITTED: YES 0 NO❑/ MFIXTURES'1 FLOOR BSM J 1 1 .2 j 3 J 4 J 5 6 1 71 8 is I 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ' DEDICATED GREASE SYSTEM ' 8 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN ' INTERCEPTOR(INTERIOR) I ' KITCHEN SINK LAVATORY ' ROOF DRAIN SHOWER STALL , A SERVICE/MOP SINK TOILET • `1.1v URINAL v .r me vier r WASHING MACHINE CONNECTION aTSR l NC vS -- / . r Ft' , 0 HE po F''''r A e DEC 2 C 2014 ' , , - , r r V IiJILUIi+ll �� ••� i•“ INSURANCE COVERAGE: I nyia'bilIlvinsumncepolicy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO [I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY OTHER TYPE OF INDEMNITY❑ 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 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 corn co with all PeNrtenl rvIsIon of the Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. il} (1,--.1 /sr/ PLUMBERS NAME STEPHEN A WINSLOW ILICENSE# 12298 SIGNATURE MPD JP • CORPORATIOND# 3281 PARTNERSHIP❑# LLCD#I I COMPANY NAME E.F.WINSLOW PLUMBING&HEATING CCul ADDRESS I8 REARDON CIRCLE • I CITY SOUTH YARMOUTH I STATE MA ZIP 02664 I TEL 508.394.7778 FAX 1508.394-8256 CELL I EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM `4°" ► & te . --- : / ti2114 ---•. .. a / ;, The Commonwealth of Massachusetts • - ��=—a �/ • Department of Industrial Accidents =€litli-;" ,' Office of Investigations • %_` (rs 2 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 Name(Business/Organization/Individual): E.F. WINSLOW PLUMBING & HEATING CO.,INC. • Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 66 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6., 0 New construction listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub contractors have g. ❑Demolition workingfor me in anycapacity. employees and have workers' P tY• 9. 0 Building addition • [No workers' comp. insurance comp.insurance.* 10.0Electrical repairs or additions required.]' 5. 0 We are a corporation and its '3.❑ I ant 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 ti I must also fill out the section below showing their workers'compensation policy information. t Homeowners vrho 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 subcontractors 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.#:1764A Expiration Date:01/01/2015 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 that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify un e p nyy and pe allies of perjury that the information provided above is true and correct Sienature: a/ ..w!w� Date:2014 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: Phone#: MAS ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a^aa ryC CITY t in r 1t _—.I MA DATE /2 2V' /,/)PERMIT# 4130-/t16-.1%/5; 3377_ JOBSITEADDRESS , £ S � a i 'WNER'S NAME gig bre) j G N. OWNER ADDRESS 9/n/1 n.zyflff- I TE La SI FAX-- ----I 'J TYPE OR OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL j RESIDENTIAL PRINT CLEARLY NEW:._) RENOVATION: ...i REPLACEMENT: PLANS SUBMITTED: YES_J Noer APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 l` BOILER —,J,_._-1 J--j.,---1— J ._...r I ___J1 _I-.-_J_ _1_,I- _I_. .-.! BOOSTER - _- J L. .... CONVERSION BURNER - I—JsJ—�_ _,, _.J_.J _J_ J_ J____J ,j____J _ _CONV STOVE _ __I_____L____ 1 1___4_____1_____I__ J'--J__J, ._J-___J _J DIRECT VENT HEATER 1 _. J I._. 1 -_.1._ _I _._I __J__.__1 . :J _ ._. }_ ..__I_ �T:._J _ .__' �p _DRYER 1 J _I_ 1 _J . .J Q FIREPLACE - . - I..._ J .J_. J1 J J J ,__, 1 J 1_. _ . _ ..; FRYOLATOR - .1 _.__ J_J J ..� J . __J J .- J ' J 03 FURNACE J—_ J-1 _J _1 J __J_._J _.J I ' _ GENERATOR J; I ,4 ME _ J J __ 1_ _. GRILLE INFRARED HEATER - J- __J __.J J _i__ ._ LABORATORY COCKS J . _�= Mall. -I -_ 1._. •,x1 _ . _J MAKEUP AIR UNIT J __.1 1 1 _ J J OVEN I _ 1 1 .1 „ .J J' POOL HEATER 1 1 J, _ J _. . .1 ROOM ISPACE HEATER • l ROOF TOP UNIT 1 _ J --1_ J1 , L_J I _. . I _- J -1-_--.' J I. . TEST J .__ 1 _I _ J 1 _ _.J J-.-_jz, J __ I J_._ UNIT HEAT R _I_ .. J J;=_ J j I ) 1 _ I 1 I V-r .. R' 1/41 HEATEJi D 1 . ._ 1 r._, 1 � i i t i I ._I ._. J _I J - 1 I 1 - - O ER iftwr Ii i 1_ 1 .1..J. J _J DEC 12.2014 i J . i J _1 .. J _I _ _J ._ .1 J -._1 1 .._ ' 1 --- I BUILDING. tvlThiENT . _.. _ t__.. 1 ._._1_... I ._ 1 . ._ i 1 _._..,__I ._1 . ..... ._._ J i By _-- --- INSURANCE COVERAGE • have a current Jiability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I/I NO , I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW . LIABILITY INSURANCE POLICY ..d OTHER TYPE INDEMNITY _; BOND L..5 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 _. . 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C��./( PLUMBER-GASFITTER NAME STEPHEN AWINSLOW LICENSE# 12298 �-�2SIGNATURE � .M�� MP /.1 MGF ._-_i JP _ JGF- __, LPG! ., ; CORPORATION !# 3281 i PARTNERSHIP _J# i LLC _1# ' COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING COd ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA ZIP 02664 'TEL 508.394.7778 FAX 508-394-8256 . i CELL. . , IEMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM ., The Commonwealth of Massachusetts om Department of Industrial Accidents It _t= _ Wr , i Office of Investigations l_f_� 1 Congress Street,Suite 100 Wi Boston,MA 02114-2017 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E.F. WINSLOW PLUMBING & HEATING CO.,INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): LEI I am a employer with 66 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* • . have hired the sub-contractors' 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 doingall work officers have exercised their 11.0Plumbing 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.] May 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.it:1764A Expiration Date:01/01/2015 p' , 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 that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un e p ni and pe aides of perjury that the information provided above is true and correct Signature: Y «..l..r Date:2014 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: Phone#: