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HomeMy WebLinkAboutBLDP-19-003996 A-7/nvt4Q /}j>as2 /MVO tar MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ak( ;C CITY L_Sou a 1TH j MA DATE U 2—!J -'7NJ PERMIT# 61-49Pelf r JOBSITEADDRESS I/c.SyWLAni� J OWNER'S NAME _ ,__ *_ P OWNERADDRESS I z-9Jz f rFI / erg,./ 3EL177y fes, ZdEAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIALW PRINT • CLEARLY NEW:D RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES El NOD FIXTURES 1 FLOOR-. BSM 1 2 3 4 ©0 7 8 9 19 11 12 13 14 BATHTUB - ` i atsaslaller CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM gm ` pisma DEDICATED GAS/01USAND SYSTEM jrnisLnisimins.,1111nigiailaa DEDICATED GREASE SYSTEM F _ (' 111011 - DEDICATEDGRAYWATERSYSTEM DEDICATED WATER RECYCLE SYSTEM IMISINIallaillaanWilli DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER [ � I 4- FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK _ LAVATORY ROOF DRAINAIN FOOD DISP • OSER _ _ [ r SERVICE!MOP SINK , INMEnnitialSanalitI. TOILET alint111011111 - URINAL WASHING MACHINE CONNECTION F j I ' I" ,SI I • WATER HEATER ALL TYPES WATER PIPING allantlialleitallann- I OTHER I � _ i� I _ _ I . �n � I fR �� ll� �li� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.-142. YES El NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 9 OTHER TYPE OF INDEMNITY 9 BOND OWNER'S INSURANCE WAIVER:l 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 Q SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application ar= 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 i lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME FTEPHEN A.WINSLOW 'LICENSE# 12298 IGNATURE� MP(i JP© CORPORATION[]# 3281C _ ,PARTNERSHIP[#L. ...... ...,_jLLCD#r COMPANY NAME E F WINSLOW �_....._______-- ._. ._..- ADDRESS BREARDONCIRCLE CITY SOUTH YARMOUTH _ _STATE MA J ZIP 02664 TEL 508 394 7778 FAX 508 394 8256 CELL. JEMAIL fA000UNTSPAYABLE EFWISNLOW.COM cT .D ,grimed o$Aasra,Accsaemy w,I, }r cOffice of Investigations 1.-416-Ii _ y 600 Washington Street Boston,MI 02111 • s yJ� •. v�GY. www.snt8s gov/d1a Workers'Compensations IInneurarece Affidavit:Thafd lersfContractors/lElecfrlelosas/2i bels }Applicant II or motion Please Print Lealbly .• . game(Business/Organization/Individual): e.F.Wtrtsi Ori stu%niounci &gceS' tj, C®) I4t. • Address: <' � .th Pockan Cat _ ' 0 (j City/State/Zip: SoGArt .. -1,1 t4Pc Phone 0: fib-399.117Vt Ire you an employer?Check the appropriate box: Typo of project(required): • .iI am a employer with 70 4. 0 I am a general contractor and I • 0New construction .employees(full and/or parttime).* have hired the subcontractors :0 I am a sole proprietor or partner- listed on the attached sheet 1 7. 0 Remodeling . • ship and have no employees These sub-contraottors have 8. 0 Demolition - working for me in any capacity. workers'comp.insurance, g. 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 0 I am ahomeowner doing all work . right of exemption per MOL 11.0 Plumbing repairs or additions . myself.[No workers'comp. c.152,§1(4),end we have no 12,0 Roof repairs . :• insurance required.]t employees.[No worker's' 13.0 Other comp.insurance required.] thy applicant that checks kill must also filloatthesectionbelowshowingtheirworkers'compensationpolicylnfonnation. • Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :oorntractop that the*Ns box must attached an additional sheet showing the name of the sub.contractoraInd theirwortcers'camp.policy information. 'km an employer that fs providing workers'compensation insurance for niy employees. Below is the policy andJob site ormdtion. — � =maceCompanyName: t�1/��CYl i' CIJti/O,AI ,t.trott000- 'Cmi ni olicy#orSelf-ins.Lie.0: M'3 I A' Expiration Date: c—i" aDi•1 ' • )bsite Address: G3 tfltrrlw-2J4'h Att-t) 04e3 1' Will City/State/Zip: O '4b'7 ttach a copy of theworkers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL a.152 can lead to the imposition of criminal penalties of a ne 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 —fupto$250.00ada # t the violator. Be advised tacopy ofthisstatement may beforwarded tothe Offceo vestigations ;or insurape overage ven a on. r • do hereby cert.&un a tas an penalties of pe jury that the information provided above it true and correct. !gnatu&afit Date: la 3 l i aOlgre hone#: .S'vl•3T'1.777g • Official use only. Do not write In this area,to be completed by city or town official • City or Town; Permlt/Lteense0 Issuing Authority(circle one): c 1.Board of Health 2.Building Department 3.City/TownClerk 4.Electrical Inspector 5.Plumbing Inspector \ U 6.Other Contact Person: Phone#: MASSACHUSETTS UNIFORM•APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK D6 , '- L= ` CITY :-P0 '1 6 22a4 MA DATE ajLile:-L&di PERMIT# g /9- ° 5 '? C JOBSITEADDRESS:it 8 thYdr7' IsZ/vc OWNERS NAME , v 2-4 1 't G OWNER ADDRESS7- > ?7�f'RT r{�£ C1a AITEL'7a'/1�7, j },S;FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL;,,] EDUCATIONAL at RESIDENTIAL;1 CLEARLY NEW:'. RENOVATION: 0 REPLACEMENT:4 PLANS SUBMITTED: YES...11 NOD APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER SAMSNISIMMASSIMSMIIMI BOOSTER SIIMIOSSEEIM ®SPOIRAMMIINIMISSIO CONVERSION BURNER WiNkteiMINIMINAISNISISSOISEMINISEMNE COOK STOVE allalaIMPOINIANSSIN DIRECT VENT HEATER INNISMIIISOWIFISIMININSWINFICIPASS DRYER SISIMEPIESl ( Mb _I _TIS FIREPLACE IIi IJOMIJ' SI SIMINSIONSIONI GRILLE ON FURNACES ] 'iOSIS � • GENERATOR S �� FRYOLATOR ' INFRARED HEATER MINNIIIIIIIMMISISMINIIIMILMINIMPOMISINIM LABORATORY COCKS 110111111111110011.111.111111MINISNIIIIIIINENNINWPIPS MAKEUP AIR UNIT [ 1L NMS; JSJ j I�Rl l i 1 OVEN I1• — Olt i r � . • POOL HEATER ' ] PPagallini PPIIII p ROOM I SPACE HEATER etIM � A ROOF TOP UNIT ] StfSIIM IM TEST sM 'n ss�a� M M�1M SS UNIT HEATER ��jl�l�ll�®gSIJt®MPIPIIIIMPIRI UNVENTED ROOM HEATER IINNIESINSIBIASSIINSISEPIR WATER HEATER_. .............. _-. . .WAMNSNMENIIIIISIMINISIMIIIIMINISNIONSINI OIHER..-...._. .-...._..- .- . . ..IMINCMIONIMIIIMM®ONS] S ® • p _ NINWlll AIISSIll INIMPIIIIIISINFISOMISI®SIIIMMOINCOMMISMININIMMITIMINXISTRIMINIjf INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L i NO J I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW . LIABILITY INSURANCE POLICY.4.1 OTHER TYPE INDEMNITY J BOND U • 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 .,,.i AGENT i.-} SIGNATURE OF OWNER OR AGENT • I hereby certify that all of the details and Information I have submitted or entered regarding this application are tru d accurate to the best of my knowledge and that all plumbing work end Installations performed under the permit issued for this application will be In comp! a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • . . . � B0-' PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE#:12298 SIGNATU axe MP.,J MGF,,,.I JP ,.,I JGF J LPG!J . CORPORATION•+]#;32816 I PARTNERSHIP'.t#• J LLC Jit...--..---, COMPANY NAME E F WINSLOW PLUMBING&HEATING 3 ADDRESS•8 REARDON CIRCLE . CITY SOUTH YARMOUTH ` STATE i MA }ZIPi02664 _ !TEL'508 394 7778 I FAX;508 394 8256 1 CELL:NIA 'EMAIL.accountspayablepgefwinslow.com Department of•11#aartr$tt$yflc�m 1 '/ r ®wee of�ada�estlgtstlort 600 WcLthlwgtorgStreet } _ r:o$tora,lug 02111 mr ennsati®rn][misses a mcg avavay ratasrg goa/dio ' Workers'Co ID davit:li adders/Contmeters/Eleetriclane/Plumbera pplicant Information C I.1 n I Please Print Legibly .• fame(Business/0rtgl1anGstlontlndividuai): Edc.Wrr�$IOW Y�V�lpi„tel 2..0e OA; VG I✓1C. .eldress: Qeotkwn c341Z_ ' • :ity/State/Zip: yoo kt1 1Mc,,,tiet p{Pr Phone#: 'SO •319.-11?SI . . Nre you an employer?Check the appropriate box: Type of project(required): I ama employer with 70 4. 0 I am a general contractor and! 6. 0 New construction •employees(full and/or part-time),* have hired the sub-contractors 1 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. ❑'We are a corporation and its required.] officers have exercised their 19.[]Electrlcalrepairsoradditions 1 am ahomeowner doing all work , right of exemption per MOL 11.0 Plumbing repairs or additions , myself[No workers'camp. c.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 checks box#1 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 mustsubmh anew affidavit Indicating such ntiactop that theoldils box must attached an additional sheet showing the name of the sub-contractors kisdtheir workers'comp,policy Information. m an employer that fs providing workers'compensation insurance formy employees Below is the policy andfob site 1 ormdilon. [�,�� r 44 • IranceCompany Name: AranJJ t-‘011/0A i•tuunCe. cretneketi • icy#or Self-ins.Lie.#: I'3 1 P • . Expiration Date: (-[ — ant-) . t Site Address:P.3 Grin/Pura kAce 0-[}t1 Ay CkS i4 11111 City/State/Zip: Oa+4 fo l 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 MOL e.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$250.00ada a:ainstthe violator. Be advised fiat a copy of this statement may be forwarded to the Office of 'estigations i the DIA•for inure ie: .overage vent a.on. i as , \--..... b hereby certify an,e . e atns an'penalties o pe fury that the information provided above is true and correct. ,: : , fir, Date: b. i aOtC t \�" one#: .5111:31\t 777k • 1 Official use only. Do not write In this area,to be completed by city,or town official • City or Torn; Permit/License# `4 ci Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cltyirami Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: