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HomeMy WebLinkAboutP-20-974 60 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK __"�'tif_ e�'� CITY�� jelb/40 urr ��sl r,;... J MA DATE[ ..'. u�`.�"/y_I PERMIT# � �0 6� '00 7 r y NER'S NAME p a/b 57 JOBSITE ADDRESS rj Z . /N2.. . ... J' ..... /fJ +! ,l? 1 OWNER ADDRESS Li It t_Tx_ vei / I�9Zr✓D .r TELI�f'/Y0 6 .G.i FAX L .,._�. - ..... Ozd47- TYPE OR OCCUPANCY TYPE COMMERCIAL I-_.I EDUCATIONAL Li RESIDENTIAL Tr PRINT CLEARLY NEW: RENOVATION:El REPLACEMENT:17: PLANS SUBMITTED: YES fl NOt , FIXTURES Z FLOOR—I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB a i - € CROSS CONNECTION DEVICE , 1 C DEDICATED GAS/OILISAN WASTE SYSTEM (T I [, I i I ( 1 ,F , DEDICATED SPEC f D SYSTEM DEDICATED GREASE SYSTEM I,_ J. i,.� r F _, 11 1. DEDICATED GRAY WATER SYSTEM 2: _ I ( ( I l C AI.- _ DEDICATED WATER RECYCLE SYSTEM , , � 1 _-` i'-'_ t--- DISHWASHER I__ s __.__ w,_ _ p DRINKING FOUNTAIN _ ' ') FOOD DISPOSER L 1 .-: � I r I_ I [ [ I ,I FLOOR/AREA DRAIN 1 - _ INTERCEPTOR(INTERIOR) KITCHEN SINK I LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK I .�. I I , ( I [ TOILET - _ , i URINAL #am_ II it- I-- t ------f _ WASHING MACHINE CONNECTION 11 1 x'I fl [ I , g p , .�.-v"�'",,..:�7,;a i�L_..: s s, "n'- ' r rt ra ;. rrrr_'p -szzi,...vr r- sue" WATER HEATER ALL TYPES ,t— „ .._MOM - ate. . : = , ..- V WATER PIPING ... f " ' ( , -,�,, i -., ,, �_ p` I�OTHER 47 ,€ 1 ' I f I l I l 1 NJ 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 J IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LI OTHER TYPE OF INDEMNITY I BOND Li 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 [.1 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 ue 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 c pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. e/� PLUMBER'S NAME!STEPHEN A.WINSLOW LICENSE#'12298ry SIGNATURE MP JP IA J CORPORATION#[3281 C PARTNERSHIP i #I LLC ,a J# , COMPANY NAME E F WINSLOW PLUMBING&HEATING . ADDRESS 8 REARDON CIRCLE CITY'SOUTH YARMOUTH _ mmJSTATE I MA ( ZIP 02664 TEL 508 394 7778 1 FAX 1508-394-8256 1 CELL,N/A EMAIL (ACCOUNTSPAYABLE@EFWINSLOW COM 46 6� t-R 1-i1- 1 _ The Commonwealth of Massachusetts -��1 = t Department of Industrial Accidents e�l= t 1 Congress Street Suite 100 y _�;1 f s. Boston,MA 02114-2017 ' ,•-,'��' WWw.mass gov/dia \Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY.A !leant Information Name E.F.WINSLOW PLUMBING&HEATING CO., INC Lease Print Le 'bl @usiness/OrganizatioMndividual}; Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: 1.0 i am a employer with 88 employees(full andtor part-time).* Type of project(required): 2.01 am a sole proprietor or partnership and have no employees working forme in 7 ❑New construction any capacity.[No workers'comp.insurance required.] 8. 0-Remodeling 3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]r 9 ❑Demolition 4.0 lam a homeowner and will he hiring contractors to conduct all work on my property. 1 will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. l l.0Electrical repairs or additions 5.0 Lam a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6•1:1 W :are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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. lam 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 01/01/2020 Expiration Date: 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 anda 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 ie pal s red pen !ties 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): \ I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other \ --'s.. .-.N\.) Contact Person: Phone#: N j MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =" e h o/2 - MA DATE / 9 / PERMIT#� � JOBSITE ADDRESS .SI .�J�;j�__(.1.,e oD_..YR. y G/7IWNER'S NAME Ipf!v./,p 5rifig22l-/Z./f'-- . GOWNER ADDRESS .t . ...✓_,:-/1 Yx„z., d_ •TEviye, ,7y-1FAX . TYPE OR OT2.O6_— PRIl�T OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: -J]� PLANS SUBMITTED: YES0 NOj APPLIANCES 1- FLOORS-4 BSM 1 2 3 4 5 1 6 7 8 9 10 11 12 13 14 BOILER . ... -- Il IW -, I._ in ._ _...___ --.-_ :--_M i BOOSTER OVE 111111.0MMIONIMM EMI® I �I COOKER CONVERSION BURNER I I®I�OOI I �r J�t DIRECT VENT HEATER INNII INIMMIl ININIM INI��11®JWO MI DRYER- - - ��M--.:__ .. .-. W� � FIREPLACE L - L - �' 1 - -. . - .." rg FURNACE - _ iI I _ FURNACE .J GRILLE 11._ MN �an �i _� . - INFRAREDHEATER [� ._. -IS -_ _ _. � J--�--.!ill _. I���I-- �� -- LABORATORY COCKS MAKEUP AIR UNIT ��� �i [ ��imintink �_ OVEN '[�� HEATERmolum mit NW an um No MI JI ���� POOL HEATER ROOM 15PACE � �-�- � 11---�--, U --� �'I�� Q. UNIT-------------.-- .1 -J L®Ih��® ��M «! --- -, MININWIMMII UNIT HEATER �� � �hl�„ TEST I� UNVENTED ROOM HEATER 1.1111111111111MIMMINIMilmountiMMMWout WATER EATER li*��--�-L ��'!� � I M�'L ilt p A` OTHER NNW � �'m — — Illo a '.. ._ -..._.._.----- . _.._.__. _IIw__IM INSURANCE COVERAGE ® 1�11® I have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES td NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E' OTHER TYPE INDEMNITY Ell 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 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 tru 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 ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW . . ._•._ , .LICENSE#_122981 SIGNA RE MP 0 MGF© JP 0 JGF 0 LPGI© CORPORATION Q#I3281C_. _ I PARTNERSHIP Oil _ - . :1LLC[]#_ COMPANY NAME:,EFWINSLOWPLUMBING&HEATING --.,�ADDRESSI8REARDONCIRCLE ,, _ - __._. .__. . _ ... _.... .I A CITY I .OUTH Y -�OUTH. _�._��._...�_.. .. _ . _._.,! STATE MA 'ZIP 02664 I TEL 1508-394-7778 • 4 S. . ._, . ..� FAX 508-390256 CELLI N/A . , _• jEMAIL accountspayable@efwinslow com _ — The Commonwealth of Massachusetts • qi _ii 1,�,f Department oflndustrialAccidents ;el r= 1 Congress Street,Suite 100 e-401,= 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 Ci /State/Zi SOUTH YARMOUTH, MA 02664 508-394-7778 �' P� Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 88 employees(full and/or part-time).* 7. El New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity-Dlo-workers''comp.insurance required.] 8. Remodeling 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on myproperty.er I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or aresole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.[ 13.❑Roof repairs 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. \\ :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 Q. information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic.#:1909A 01/01/2020 Expiration Date: 0 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 pat s¢nd pen lties of perjury that the information provided above is true and correct .4 Signature: ? .•..o� Date: t . IN Phone#:508-394-7778 Official use only. Do not write in this area,to be completed by city or town official IN City or Town: Permit/License# Issuing Authority(circle one): P City/Town Board of Health 2.BuildingDepartment 3.Cit /Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other (C Contact Person: Phone#: �l