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HomeMy WebLinkAboutBldp-19-002435 snh MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,, z _t!= CITY _YI r fl d— -- - - -_ , MA DATE�Ii j_ PERMIT#/ �� a1�g`M »1 ..„ JOBSITE ADDRESS��(� R�f�Ln ISAG�tI IA}ft,�.Yj�( }�OWNER'S NAME 111,d-1 J G S Kfe t- rhino - oac-13 P OWNER ADDRESS 1 HAS4 1 A5S QJ \e54•/7V1 M A O rI i i TEL 5DV?'�V -2y 1 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIAL[ — PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:are-- PLANS SUBMITTED: YES 0 N00 FIXTURES Z FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE On DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM illiii illlii®®®���_M IMI DEDICATED GRAY WATER SYSTEM ®��� DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN I o- s tkii.1 ___ __ , FOOD DISPOSER 1 r FLOOR/AREA DRAIN NI' 1 _INTERCEPTOR(INTERIOR) - , -- KITCHEN SINK E=EP 1111M111® LAVATORY ROOF DRAIN SHOWER STALL illion_ - SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES . L- `_ 4.--__ + WATER PIPING IL .2,m OTHER , INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the •I iremen . of L Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPRo P'IAT :OX: LOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 :OND 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. 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 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. //�' PLUMBER'S NAME STEPHEN A.WINSLOW ��� _ _ LICENSE# 12298 SIGNATURE MPO JP0 CORPORATIONO# 3281C PARTNERSHIP®# LLCO# COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE _ _ - CITY SOUTH YARMOUTH _ _ STATE MA ZIP 02664 TEL 508-394-7778 _ - _ FAX 508-394-8256 CELL N/A EMAIL I accountspayable@efwinslow.com Sg1.2\ 11LL- L-VIILIILVIL IYL-LLLLIL IV 1I16LJJLLLRLKJ6,11,LJ Department of Industrial Accidents • `�,f Office o Investigations s _5� _. 4 600 Washington Street � _ Boston,NIA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 1pplicant Information Please Print Legibly Jame(Business/Organization/Individual): E.C.I -t, s10,,,; QV,,_.A,.. .. . 11-eQk-,'ivx c > Ic( ddress: Ys (4 adtin CI rt,t(2— i ity/State/Zip: So,s ,,,,,c,J -, l-Or Phone#: IDS- 399-7`rn re you an employer?Check the appropriate box: Type of project(required): AI am a employer with 70 4. ❑ I am a general contractor and I 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. El Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers'comp.insurance 5. 9. ❑Building addition p ❑ We area corporation and its required.] 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 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. lomeowners 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. zm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. surance Company Name: .,J tv•1-•tie-A ,__Lill`chat c , ' . Ca 111y )licy#or Self-ins.Lic.#: 1 3 D.I A. Expiration Date: (—I - aOi9 b Site Address:a3 G cc1 j.. OJ AAR) C623 I 11 City/State/Zip: OaLI( 7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a le 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 t•.t a copy of this statement may be forwarded to the Office of ' '...c.-.0.4 vestigations • the DIA`•for insura••- overage veri .j on. to hereby certify un e e ains a i penalties o i'jury that the information provided above is true and correct. •natu3=: � ,,t, _ - � Date: 1 a i ao i7 tone#: cb :314- 777X v 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 v(' 6.Other � ` Contact Person: Phone#: \� ��_� i n, 14, i°'- _ MA-DATE WlihU1 PERMIT# n/�1'-/y-O©vZ[ /� � .= CITY _ = JOBSITE ADDRESS '10 R[d Rt wW4-YAkfA1ewe1► I OWNERS NAME NM,_ G as-1-3 �. TE 1 , FAX OWNER ADDRESS _ TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATION RESIDENTIAL( PRINT PLANS SUBMITTED: YES® NOD CLEARLY NEW:D RENOVATION:© REPLACEMENT: APPLIANCES 1 FLOORS-4 I BSM l 1 1 2 3 4 5 6 7 1 8 9 10 11 12 13 14 BOILER — -_— _ ___ - _ BOOSTER CONVERSION BURNER - MI NM Ina COOK STOVE - _— _ _--- - -- DIRECT VENT HEATER -- DRYER MNFIREPLACE MI MI FRYOLATOR - - - - _ FURNACE w---- --" ---- MI CM MI OMOM OM IIIII GRILLE - _ INFRARED HEATER LABORATORY COCKS -- - NM NM OR OVENMI MIR MO MAKE AIR UNIT __.-A------ - -- ------ - --- _ _ - OVEN POOL HEATER - - - r--_--- iiii MIN - iiiii Mai in ROOM 1 SPACE HEATER ROOF TOP UNIT IIIN MI MI TEST _ ri UNIT HEATER - - r= UNVENTED ROOM HEATER WATER HEATERmini in® . OTHER - - immemiummagehm Min MI NM ._ -^ '-___-T, INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE INDEMNITY © 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. CHECK ONE ONLY: OWNER® 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 compliAi i with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4 ; , 4-4/ PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 � SIGNATURE MP El MGF® JP0 JGF® LPGI® CORPORATION0# 3281C PART NERSHIP®# LLCO# NM COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY I SOUTH YARMOUTH 1 STATE MA J ZIP402664 1TEL 508-394-7778 FAXI 508-394-8256 I CELLI N/A ,EMAILI accountspayable@efwinslowcom tie 1.4._ • i le - Ull A 0611. 6-.1Oy0a00.0.,60Y S.a66606%5 ✓tri assuca¢.o6 yaacaau Department of Industrial Accidents 444 4 _s�� Office of Investigations ->- E'se�e�aw.= 600 Washington Street • '� Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers licant Information Please Print Le ibl MC(Business/Organization/Individual): E.C.IN tytS i Ow etU.42- $ {a-V.. , a. IrtL. dress: oev1 • y/State/Zip: as A v„bo Phone#: SUE-394-1Vg you 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 p have hired the sub-contractors I am a sole proprietor orpartner- 6. ❑New construction listed on the attached sheet.fi 7. ❑Remodeling ship and have no employees shipwor andg for e ein anyyes These sub-contractors have capacity. workers comp. insurance. ❑Demolition [No workers'comp.insurance 5. 0 We are a corporation and its 9. ❑Building addition required.] officers have exercised their I am a homeowner doing all work right of exemption per MGL 10,❑Electrical repairs or additions myself.[No workers'comp. C. 152 ❑Plumbing repairs or additions insurance required.]t §1(4),and we have no 12.❑Roof repairs employees. [No workers' comp.insurance required.] 13 ❑Other iplicant that checks bok#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 must submit a new affidavit indicating such. • ctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 'n employer that is providing workers'compensation insurance for my employees. Below is the policy and job site lotion. ace Company Name: f10 eA oecl n ,r1 #or Self-ins.Lic.#: 126 J A L Expiration Date: t—1 — aOI9 :e Address: C1 v;2Q.-!�'1 1�2 C :L.,1 ��, — 1 a copy of the workers'compensation policy declaration page showing the tpo icy number expiration date). to secure coverage as required under Section 25A of MGL c. 152g can lead to the hn o to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a 'P__ D$250.00 a da a:ainst the violator. Be advised t i.t a cop srtlon of criminal penalties of a STOP WORK ORDER and a fine gations the DiAfor insuraI - of this statement may be forwarded to the Office of overage vert on. reby Certify!dn e a1nS a i! . / penalties o —jut);that the information provided above is true and correct. Date: (1 i apt- • :id use only. Do not write in this area,to be completed by city or town official. • �+ or Town: • ng Authority(circle one): Permit/License# lard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector her p \ act Person: • Phone#: •