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P-19-6943 ; i% MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 7.5 i=" MA DATE 6/5 19 PERMIT#/ `='a=a� CITY I Yarmnu�11 JOBSITE ADDRESS IaICamcio-f Rd Yivinad-In 01615 J OWNER'S NAM 5usan /kW et/ � OWNER ADDRESS��4.36 SpU+k 6b Ea5}A vt' �-1 TE •I: '3 i► : '�'� 3 ' FAX P 1 i33 TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATI AL 0 RESIDENTIAL PRINT PLANS SUBMITTED: YES® N00 CLEARLY NEW:® RENOVATION:® REPLACEMENT: FIXTURES 1. FLOOR-- BSM 1 2 3 4 5 6 7 8 9 10 -11 12 - 13 .14__ BATHTUB MM.iiii 0111.1.1111111111.1111.11111.1111111- 1 MI OM MN OM OM MI CROSS CONNECTION DEVICE UMW NIAPMIWOOMPM�MI - --- DEDICATED SPECIAL WASTE SYSTEM IN IN iilliiMilli11111.11.11111 ON 11111.11 NM ON PIM OM DEDICATED GASIOIUSAND SYSTEM 1111111101.1111 gm ImmuiN1111111•1111111.1.11 NM MN Mt OM MI PIN GREASE SYSTEM - -_ DEDICATED'GRAY WATER SYSTEM 11111111 DEDICATED WATER RECYCLE SYSTEM I♦ r , ippon um U MI --—---DISHWASHER---- --- -- - MEM l - - INI MINX UN DRINKING FOUNTAIN MOM MI - IOIIMIIIIIIIIIOIIPIMIIIOIII_ :1171111111 MI MN MS OM MI PM — = �� FOOD DISPOSER FLOOR I AREA DRAINIllil._ m MINN ----- INTERCEPTOR INTERIOR) ---- - KITCHEN SINK l N,i _ ;�MIU LAVATORY M -•__ ---_- -.- - _- _- ROOF DRAIN �_NM- M'MI I U SHOWER STALL MiaINl MI MI OM MI MN SERVICE 1 MOP SINK IiIii ingiall.111.11111111.11111IM Mili ill.PM OOP INN MI UM NM MN TOILET _MOM—_ MMIMI URINAL - - -1.MI OM UII i WASHING MACHINE CONNECTION NM '�OMOMN iiiii MN NMI MI MO WATER HEATER ALL TYPES mow NE _illIMINIMIIIMIll IIIIIIIMMOIll—M MN MN ON��_ WATER PIPING OTHER - inEilii MI MIIIINIMMINIMMI11.111 MI NMI Ma NM Mill MI _ NMI=M NM IN MI MI �" Y MIUNMR�OM INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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® 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 a 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 complia e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I STEPHEN A.WINSLOW ILICENSE#112298 1 - SIGNATURE 5' ' MP(] JPD CORPORATIONQ#L 3281C IPARTNERSHIPED#1 1 LLC COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE - CITY`SOUTH YARMOUTH I STATE MA 1 ZIP 102664 TEL 508-394-7778 FAX 1508-394-8256 1 CELL N/A EMAIL accounts payable efwinslow com - The Commonwealth of Massachusetts Department of Industrial Accidents E;EJifl:' 1 Congress Street,Suite 100 E_ f= Boston,MA 02114-2017 s� www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. 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): LEII am a employer with 88 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. [:1 Remodeling any capacity.[No workers'comp.insurance required.] 9. 0 Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOF repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any 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. tContractors 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.#:1909A Expiration Date:01/01/2020 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and a pai s nd pen !ties of perjury that the information provided above is true and correct. Signature: ..,__ r .,� _ Date: n Phone#:508-394-7778 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): .. N 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ', Contact Person: Phone#: i . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK --_G_ CITY �afm27uf(� . ___.... .. ......._..._._._ • MA DATE LS.L�.q..__ 1 PERMIT#/ D13'/9"9 JOBSITEADDRESS 1.-If,.0fla .Rayaffrpy,-l,O.2-6-i5.OWNER'SNAMELS; t ,_ k;nt-M_--______._._..._.1 GOWNER ADDRESS ckli6., tlig .6,6 46+A?►✓owelJ. K_-.TE4 1t1,63_O0_1,3.?-1 . ..IFAXL-------.----..I TYPE OR OCCUPAlm TYPE COMMERCIAL[] EDUCATIONAL 0 RESIDENTIALEK PRINT CLEARLY NEW:0 RENOVATION:Li REPLACEMENT: PLANS SUBMITTED: YES NOD APPLIANCES'1 FLOORS--I BSM 1 2 [ 3 4 5 16 7 8 9 10 111 12 13 14 111111111 BOOSTER �*1 --..min .. 1.�_._)...._ L. initilisilllitremit CONVERSION BURNER M COOK STOVE UNICIPM DIRECT VENT HEATER Mi _ IS llM _____Imummin- WIWI 11111. 1111-1-10Wil** MINIM. .:1M1111.1 FRYOLATOR FURNACE — - �►. ._-.1 ---. _ -.-iM - • Imo; ._ • WILMI JI�MOMIIM ® -..., .- INFRARED HEATER 11111MannollOWNIIIRMomiNINPRIMINIWIM LABORATORY nalMUNIIIWWIR I • OVEN I ! 01 1f POOL HEATER �, i a W ,®Il .M ION ROOM I SPACE HEATER I-..._-ii �I I�MMh �MI IEM INI ROOFTOP-UNI`iL-------•-------- .. .J I�. �®� I ��_._: TEST UNIT HEATER n _�MH I �I I- ogI ��mo UNVENTED ROOM HEATERlit WATER-IEATER Milll''_ ',' .1. =- I� OTHER �I �IMa® ®®IMO lailliti5 _. ... ._ .. _,.. . . -_. _.M �I ANI II1® E® MI® L INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES O�,O. NO 1 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY[ BOND D_�.' •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 El 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 compli a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — 0 f,a- V) PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW . LICENSE# 12298 SIGNATURE MP 0 MGF El JP 0 JGF 0 LPGI© CORPORATION 0#18281 C_ I PARTNERSHIP D#) . _ I LLC DI_ ..._ _. II 2if cJ COMPANY NAME: EF IMNSLOW PLUMBING&HEATING._-.,ADDRESS 8 REARDON CIRCLE .. , • ___. ._.., . .. ..... , CITY SOUTH YARMOU7H . ... .. ...... ...... . STATE. MA-'ZIP I• FAXI508 394-8256 CELL N/A EMAIL accountspayable@efwinslow.com • .. _ ... -,.. The Commonwealth of Massachusetts } =,, 1� 1, Department of Industrial Accidents nl� 1 Congress Street, Suite 100 = Boston,MA 02114-2017 ,� www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. 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: Q p Type of project(required): l.p✓ I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doingall work myself. t 9. Demolition❑ y [No workers'comp.insurance required.] 10❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 ROOF repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.D Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any 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.#:1909A Expiration Date:01/01/2020 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and a pai s nd pen lties of perjury that the information provided above is true and correct. Signature: Date: Phone#:508-394-7778 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#: