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Home My WebLink AboutBLDP-15-000016 v /l ,n ,F7e, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK qt.:17r- .• CITY /51-ri1t/Yin IMA DATE( 67-DZ •/y- IPERMIT# P/r-c/6 JOBSITE ADDRESS 14-7 A ,fie C'P . . I OWNER'S NAME( Cu rtai I • p OWNER ADDRESS I ft/$-(4n-)lr(Jk#5 I TELh#/7.9i/7 If ffIFAX `J. TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL O' PRINT � / 1. CLEARLY NEW:❑ RENOVATION:0 L�J REPLACEMENT: '� PLANS SUBMITTED: YES 0 NO L' FIXTURES 1 FLOOR-, BSM 1 .2 3 4 5 8 7 8 9 10 II 12 13 14 I1 ,' • DEVICE SPECIAL WASTE SYSTEM SYSTEM GREASE SYSTEM rDEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN ear DI SPOSER FLOOR INTERCEPTOR INTERIOR Mi MI IIIIIIII MI MI MINI ME MN NMI OM MI MN MI NMI PIM XITCHE SINK LAVATORY ROOF DRAIN 111 SHOWER STALL SERVICE I MOP SINK TOILET . , URINAL WASHING MACHINE •,I •I , • fir ••. EI'eIMEF � > • r . i ACJ • rT re' '.a • . r a i , II 0. 71114 , Di ni.irrnENT • By _ , ) INSURANCE COVERAGE: n I ave a ctarentliability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO •rrr IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW * "' LIABILITY INSURANCE POLICY 0 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. CHEC NET/NM. OWNER"❑ AGENT 0 . SIGNATURE OF OWNER OR AGENT ] I hereby catty that all of the details and Information I have submitted or entered regarding this application are true and rat the tot myd ge and that all plumbing work and Installations performed under the permit issued for this application w@ be in compliance wtIfr, Drovldor Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C.....__®.....J PLUMBER'S NAME I STEPHEN A WINSLOW I LICENSE#112298 I SIGNATURE MPQ JP0 • CORPORATIONQ# 3281 PARTNERSHIF❑# LLC❑#( I COMPANY NAME(E.F.WINSLOW PLUMBING&HEATING cqd ADDRESS 18 REARDON CIRCLE I CITY I SOUTH YARMOUTH I STATE MA ZIP 102664 I TEL 1508.394.7778 - `.I FAX i 508.394-8256 I CELL I I EMAIL I ACCOUNTSPAYABLE@EFWINSLOW.COM •'t I • . /cia i The Commonwealth of Massachusetts ` ,' ia�-4— Department of Industrial Accidents =; i=I" Office of Investigations ' -.=1:14:_—_ ay .1 Congress Street,Suite 100 • --...v . Boston,MA 02114-2017 `a wwinmasstgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual): E.F. WINSLOW PLUMBING & HEATING CO.,INC. Address:8 REARDON CIRCLE City/Stat&Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-3944778 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 66 4. ❑ I am a general contractor and I erriployees(full 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 8• 0 Demolition working for me in any capacity, employees and have workers' [No workers' comp.insurance comp.insurance.: 9. 0 Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions "3.0 officers have exercised their I am a homeowner doing all work 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 13.0 Other employees. [No workers' comp.insurance required.] *My 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. teontractors 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.#: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. -- .. . - —s I do hereby certify un- e p ray and pe aides ofperjury that the information provided above is true and correct I- •. ature• .t . ` Awe a; ;20 4 Phone#: 508-394777 0 A Official use only. Do not write in this area,to be completed by city or town official. i. City or Town: Permit/License# t Issuing Authority(circle one): \ 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ,513 N. ' 6.Other u Contact Person: Phone#: 'R MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r ri ,/ sC CITY `/et-7i .?U is/79D _ MA DATE Or 7-OZ. / J PERMIT# 16 .5 �' /6 G JOBSITEADDRESS C , LP.rz Z"C IOWNER'S NAME w 7rra AD . _. I. ii72eYz/(y , . ITEL'6/79//'/90 piF�'� —__1 OWNER ADDRESS r • TYPE OR OCCUPANCY TYPE COMMERCIAL,J EDUCATIONAL J RESIDENTIAL PRINT CLEARLY NEW:.-„-i RENOVATION: J REPLACEMENT: PLANS SUBMITTED: YES__I NO -Y NAPPLIANCES 1 FLOORS-• BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BOILER _1_1_1 __J . , J, .I _. _J J' I I _.J __I ' BOOSTER _ J S 1 J __14.___I__.p__I • _ __., J .._.i CONVERSION BURNER ____,i _ I i__I_(J_. '_J _ A COOK STOVE J 1 i 11 , I__ J ___'J _1 (C19, DIRECT VENT HEATER A . J- - ---- - ------------- -- ---- -- -- -- - - " j DRYER __l J_ i - _.J . 1 ..__) I _..__1 __- ' FIREPLACE ‘' ' . ___A --_J=-_J- _I___, _1 _J 1 J _I _1 FRYOLATOR EOR _ -_ RNAJ I —._J__I__ _.__.1 ._ _J .,_-I _I FURNACECk J _I1 J __ _ . ) 1 GRILLE I 9 J .....1 ' I INFRARED HEATER _I__J'._.. _ I _J LABORATORY COCKS I 1 I rl 1 m.,_I MAKEUP AIR UNIT ---I OVEN - _.J ___ _ 1 _ _ - __J -JPOOLHEATER It __ J -__ _,__ . . .._.J ___ .1 . .J ROOM/SPACE HEATER __I_,_4 1 ., I .J - J 1 _ ..__' t ROOF TOP UNIT I __ 1 _' . _- _- ._i __-1 TEST OMIT HEATER 11-111Wall-i111111111111111111 -_.J } JtJ tcGOEM 111M-EE D mss s -=—i . pane - Ili. WA - • it”' r - ,� p ®� 'S __--: . �1.. _.-J� OTI-fER 4 't 2014 i. 1 - 1 T . _.___I._,_J J __. J _..__._I . I ..___I __AM _. I _ .. ) J J --1- . ._ 1 __ J -_i _- J .._.. -1 - _J®__ _! .. - -. 1 ___ J 1 _--_1 J __._ I ._J_-.- . _I _.....A__.._J I J BUILDING TMENT By _-_-f�. __ J J N _ N - J 1 1 - 1 J__1 J ""_"-- INSURANCE COVERAGE I have a current liability 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 +J • OTHER TYPE INDEMNITY _J BOND I_.! ` ' • - • 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 . OWNER/ AGEN 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 a u e to the t of my o :dge and that all plumbing work and Installations performed under the permit issued for this application wi(be in compliance wi Pertine provision •f .e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A WINSLOW ; LICENSE# 12298_ J SIGNATURE MP MGF _ i JP JGF• .--i LPGI .._i CORPORATION . ;# 3281 -_.. , PARTNERSHIP _J# J LLC ._..I# . .,. ' COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING COJJ+ ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA ;ZIP 02664 TEL 508.394.7778___,._,_,___ • FAX 508-394-8256 I CELL , _.____._1 EMAIL E ACCOUNTSPAYABLE FWINSLOW.COM off —.. _._, - ti .� The Commonwealth of Massachusetts t Department oflndustrialAccidents L-7.1* - l Office of Investigations =temp=tf.y 1 Congress Street,Suite 100 Boston,MA 02114-2017 ti a— +' wwwmassgov/dla +' 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#:508494-7778 Are you an employer?Check the appropriate box: 1.❑■ 66 4. I am a general contractor and I Type of project(required): I am a employer with 0 employees(full 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 8. 0 Demolition workingfor me in anycapacity. employees and have workers' p ty 9, 0 Building addition, [No workers' comp.insurance comp.insurance.: 10. Electricalrepairs-or'edditions 1 :? ? required.] 5. ❑ We are a corporation and its ❑ officers have exercised their '3.❑ I am a homeowner doing all work 11.0Plumbing repairs or additions- �, myself. [No workers' comp. right of exemption per MGL 12.❑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#I 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 subcontractors end 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 andJob 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, • -- - imt I do hereby certify un#.al e p• ny and pe aides of perjury that the information provided above is true and correct k/ 2014 J. stare. �. . L a... # - •at • 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): k 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ' 6.Other cilr Contact Person: Phone#: