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HomeMy WebLinkAboutP-19-5977 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT t U rltkrUrcrur rLuINIbiniv v c'-" ' CITY _ (ll f . O V I MA DATE IMalta]PERMIT# ,ram' • �f i'` � 6 _ OWNER'S NAME' �0 JOBSITE ADDRESS �1 }�, �� �. pr p OWNER ADDRESS __SF:1M _ TEL��1!l FAX TYPE OR OCCUPANCY TYPE COMMERCIAL(0 EDUCATIONAL 0 RESIDENTIAL" PRINT - PLANS SUBMITTEDs YES 0 NOQ CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:UV. FIXTURES 1 FLOOR--I BSM 1 2 3 4 5 6 7 8 9 10 11 2 1 4 BATHTUB iiii CROSS CONNECTION DEVICE 1 — I '�,� IIIII DEDICATED SPECIAL WASTE SYSTEM _i n I — -- DEDICATED GASIOILISAND SYSTEM in --- = I _, K) DEDICATED GREASE SYSTEMIn M ,� W1 y� NW DEDICATED GRAY WATER SYSTEM ',®®',IIME_no DEDICATED WATER RECYCLE SYSTEM Wat, nig bo — .=Wl —,®,NO DISHWASHER '1'I I 111_..i n,1s1111i•l11 .., •Mn, 1m,Nig11l., MIM _ -,MIM DRINKING FOUNTAIN =- - FOOD DISPOSER __ L 1i® . ~ FLOOR 1 AREA DRAIN ®!® INTERCEPTOR(INTERIOR) l_ KITCHEN SINK lO LAVATORY � IIIIIIIIIIIIII- _ ROOF DRAIN SHOWilin I ER STALL gun SERVICE I MOP SINK IIIiJ ®l URINALEH, ^ _.. izi L______=, WASHING MACHINE CONNECTION iiIiIuI _. ow WATER HEATER ALL TYPES =mom WATER PIPING WEE imm„,_ OTHER ___--- ----_--_ ;,- -_,RI= wing, ot IIIII -III , 1.11111111 - - l _ .___ NMI RR5RR , INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ei NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I BOND 0LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 Cr 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 co lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. OA/ PLUMBER'S NAME[STEPHEN A.WINSLOW __ LICENSE#U12298____1."'' SIGNATURE MPO JPD — . CORPORATION0# 3281C PARTNERSHIP #1_____._____ILLC©#I__.__ I COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 18 REARDON CIRCLE ---- — __ � CITY)SOUTHYARMOUTH_ STATE MA ZIP 02664 I TELI508_394__ _____._______.,___I FAX 508 394 8256 CELL N/A EMAIL I accountspayable@efwinslow.com _._____ ^._-___._...._______�._..._-_._____.___- _ z_l 5 A Ybb. a-'.//CCD.04/”Ir6.ygbbBb V '� J i' ,,.bb4D —w-= 1 Department of Industrial Accidents '� .__�_lio= �, Office iof Investigations • 6PP Washington Street Boston ,li�AP2111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers glicant Information Please Print Le ll ne(Business/Organization/Individual): E.c. !,,‘S e cress: Q buy ,ram r/State/Zip: feu i 1,,,0 Phone#: 53S.399. i1r/ 'ou an employer?Check the appropriate box: I am a employer with 70 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached sheet.$ ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers'comp.insurance. 8. Demolition [No workers'comp.insurance 5. ElWe are a corporation and its 9. ❑Building addition required.] officers have exercised their 10.0Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152, 1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' comp,insurance required.] 13.❑Other ilicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. wners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. employed that is providing workers'compensation insurance for my employees. Below is the policy and job site Ilion. ce Company Name: (-1J i P�2t rt ✓t • `or Self-ins.Lic.#: 1$a 1 A ��^^ Expiration Date:_104" I•- aS 31 Address:a3 G.Innm v:-e0--11 1 Gig 'j 11 a copy of the workers'compensation policy declaration page(Showing thetpoliclp number and xpiration date). Pg (� g policy ) o secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a o$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a f e e O $250.00 a da against the violator. Be advised tat a copy of this statement may be forwarded to th u� itions . the DIA for insura • ,overage veri . on. ffice of thy certify un e e®®®ains a 1 penalties o P'jug that the information provided above is true and correct. op- �,A_JAIL, Date: (�. i 1Ql' al use only. Do not write in this area,to be completed by city or town official '. r Town: Permit/License# g Authority(circle one): rd of Health 2.Building Department 3.City tY�own Clerk 4.Electrical Inspector 5.Plumbing Inspector zt Person: • Phone#: '. , ''• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �_ la 4ictfUO12±h .(-Sett)..__._: MA DATE ji/J ./_I9- PERMIT#/ 6 f-co 70 JOBSITE ADDRESS J5_.ti t hid j Q,mme..r _LR-t._ OWNER'S NAME -.Lined... -don rt1A In -- GOWNER ADDRESS ___ 5n ...._....__ ----- -_- _____________, TELl-7 -'lZq3_FAXI.._..__ ._ . -.. .1 TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL Q RESIDENTIAL' PRINT CLEARLY NEW:O RENOVATION:[1 REPLACEMENT:[, PLANS SUBMITTED: YES[] NOQ APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ;.. ._ __ ----I 1---- - I -_ I _i --- -. I- - BOOSTER [_-- CONVERSION BURNER ®®� ®I®®INN I �'•��! COOK STOVE 111111111111111111111111111111111 FIREPLACE III. .. L ` _ DIRECT VENT HEATER ®J_ �' DRYER �I�l� FRYOLATORWilnoutillillallii11111111111111111111•11111111111111m I` FURNACE I Ban __naGRILLEATOR la _IIIIIEIIIIIIEIIIIIIEIIIIIIIIMRIIVIMIIIIIEIMIIIIIIIIIIIIIIZIIIIIIIIIIMMIIIIIIIIIIIIIIIIII ^ INFRARED HEATER IIIIIIIIIIIIIIMIIIIIIIIIIIIIIIMIIIIIIIIIIIIICIIIIEIIIIIIMIIIIIIIIIIIIIIIMIIIIIIIIIEIIIIII LABORATORY COCKS MAKEUP AIR UNIT I1111111.1.110111R. ...= 1117.1 1II1—f ®' 1111111 OVEN I il( [ I! II !I�l! l li 11J I i if Jf� l l' lilf l l 1' "�l'�'[ POOL HEATER ROOF TOP UNIT HEATERROOM/SPACE 1111lFIIIIIIIIIIIIIIIHIIIIIIIIIMIIIIIIMII' IIIMI= lIIIINI TEST w ( I �il UNIT HEATER hll�;i � �' ��� �' � i' Ili WATERROOM HEATER I ll II®IWllM NI J��IW nil 1-l®' WATER HEATER �. I�1« INNI OTHER _ [ _ _IIIIIIKl l[ l l MIIIIII I_I'_I U' IIII I __J L_J ____I ____1 I_ I L.JL:.. A L J L_I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO Li IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW CO LIABILITY INSURANCE POLICY) OTHER TYPE INDEMNITY i BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Cr Massachusetts General Laws,and that my signature on this permit application waives this requirement. Q-- 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 d 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 compli e with all Pertinent provision of the I Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 ' SIGNA URE MP 0 MGF 0 JP 0 JGF 0 LPGI Q CORPORATION Q# 3281C PARTNERSHIP 0# -...,.. . LLC 0# .. _. COMPANY NAME: EF WINSLOW PLUMBING&HEATING __. ADDRESS 8 REARDON CIRCLE CITY SOUTHYARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX L 508-394-8256. I CELL NIA EMAIL accountspayable@efwinslow.com li ; J So...\ 116E Li/116116V66IY6.666616 IV 1I1660.y660,6614.)466.1 Department of Industrial Accidents Office f !_ ff o Investigations 01 Tx,=91;;_ �, 600 Washington Street x � Boston,MA 02111 `� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le °bl Name(Business/Organization/Individual): E,c.V1,,.5 i GO) Q(U+MtO1v'lC. ( �a-t - h 0... i fl C. Address: cyan it City/State/Zip:_ 0,3 1 cr,,•,,r,,,[4.1 NA- Phone#: Are you an employer?Check the appropriate box: I am a employer with � ❑0 4. Type of project(required): employees(full and/or part-time).* eneral contractor and I have am hired the sub-contractors • 6. 0 New construction :.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers'comp.insurance. 8. Demolition [No workers' comp.insurance ' 5. 0 We are a corporation and its 9 ❑Building addition I.LIrequired.] officers have exercised their 10.0 Electrical repairs or additions 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. 12.0Roof repairs [No workers' comp.insurance required.] 13.0 Other 1ny applicant that checks bok#1 must also fill out the section below showing their workers'compensation policy information. • Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. tsurance Company Name: `,y (`-‘ r , c.)1 k •nsl c n ' olicy#or Self-ins.Lic.#: 1 B a I A r Expiration Date: (—� — D. 1b Site Address:D.� �rv<c,,i1 u.��l-� � CG 1 'f ►i t�►i' F n I I City/State/Zip: d,�LI�i l \*%.-1- .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 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 F up to$250.00 a da against the violator. Be advised t e at a copy of this statement may be forwarded to the Office ofN. tvestigations • the DIA for insura •- 'overage verif .r on. do hereby certify un e e ains ant penalties o •jury that the information provided above is true and correct. is alit-: / <. UP' - -AIL Date: (a i a10i �, hone#: . 4. 7 778 C...N\ Official use only. Do not write in this area,to be completed by city or town official. .• City or Town: Permit/License# v Issuing Authority(circle one): \ 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector r -fin Contact Person: �\ Phone#: