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HomeMy WebLinkAboutBlp-19-006555 ,� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 0 ao 1py 3t� ...� tr1.-__ ', CITY 1 ' MA DATE 1 ri i i q 1(�1 PERMIT# �� — JOBSITE ADDRESS - ''-) OWNER'S NAME[-Thr,rro if I C r_i I iic n tLl POWNER ADDRESS _LAME;r __________I TELi5t - iI I 1 l .. 4FAXL 1 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL D RESIDENTIAL/ PRINT CLEARLY NEW:D RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES 0 NOO FIXTURES 7- FLOOR--I El= 2 3 4 5 6 7 8 9 ifi ® 13 14 BATHTUB "--— CROSS CONNECTION DEVICE I _ _ —_ 1 iliili DEDICATED SPECIAL WASTE SYSTEM �, _.__ _ _ — M --— , - - PIIIII WINIIIIIIINIMI I- - -- DEDICATED GASIOIUSAND SYSTEM 1 -- '— DEDICATED GREASE SYSTEM DEDICATED'GRAY WATER SYSTEM ' DEDICATED WATER RECYCLE SYSTEM till -- - DISHWASHER L-- / DRINKING FOUNTAIN r!� �� FOLOORIAREA DRAIN I.___._ —�� —I OD DISPOSER 1 1 i'-) INTERCEPTOR(INTERIOR) I I --- , NM- ' _I " KITCHEN SINK LAVATORY -- m -. _ _. __ - ----. ROOF DRAIN — ®® SHOWER STALL — SERVICE I MOP SINK ---- _- -;_-- '------. �- TOILET mil =oliiimmimmi__ _ . URINAL WASHING MACHINE CONNECTION .__. — WATER HEATER ALL TYPES WATER PIPING __. _ �— 1 _ _ — OTHER � _ _ - I I . I t 1 - INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW --4---LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY 0 BOND 0 1 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the C-- 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 t 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 corn ' nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOW — y LICENSE#1,12298 _ SIGNATURE MP El JP El CORPORATIONO# 3281C PARTNERSHIP®#______—__ LLCO#I I COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE ____ CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778_______ —,..-_ FAX 508 94 8256 CELL N/A EMAIL Laccountspayable@efwinslow.com _ ,_____,__-__-____.__.__..__`_ .-.„__________.-___..__._.� 6� • b 3 k \w"41101p,""‘ am,lb IY d etc 66Bb VJ lld 4lJJG66.B6l6alLbW Department of Industrial Accidents iii1 Office of investigations =:.= 600 Washingit ton gton Street ' Boston, www.inass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers licant Information_ Please Print Le 11 ne(Business/Organization/Individual): •C.�,ns I ow U cress: (tCi1 .ate ! /State/Zip: cu A M Phone#: '503-399-117ct /ou an employer?Check the appropriate box: I am a employer with "7o 4. 0 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. 8 ❑Demolition [No workers'comp.insurance_ 5. insurance. 9 ❑Building addition p 0 We area corporation and its required.] officers have exercised their 10.0Electrical 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.] 13.0Other plicant that checks boic#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. tors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. 1 employer that is providing workers'compensation insurance for my employees. Below is the policy and job site ztion. ce Company Name: `,,y 6v r � t-- fclrctn VI or Self-ins.Lic.#: I a i A � Expiration Date:_104- I-- a 31 Address:aJ �Mr� ,,;tw1� ,ec1 i r 1 ' '' 1 Fly 4i City/State/Zip: Doi-}I, a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). to 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 fine $250.00 a day against the violator. lie advised t I at a copy of this statement may be forwarded to the Office of ations . the DIA.for insur. - overage verij on. ii ?by certify un e e sins a 1 penhlties o•jury that the information provided above is true and correct. -AL_ Date: 1 a i a©l' ;i y• -mg ., 'al use only. Do not write in this area,to be completed by city or town official ~ • ir Town: • • Permit/License# 1 i g Authority(circle one): �{ 1 [rd of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector er et Person: • \ R Phone#: ' 1 r • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK mow• T -6 , } c ;n_ C-L ,S�) MA DATE 5/f4-_i n PERMIT b o7' 0 i .�P .��t;�- � CITY ����C�.�.�':►.. . • JOBSITEADDRESS �rL._,B yi(L4 , If-_,..•-_ _-- ___OWNER'S NAME _CfmtS. o��c:e....L it..hy, GOWNER ADDRESS LiC'1 iy,,.1->>- ........ - — TEL }-1t 127 FAX - -- - - - TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL Q RESIDENTIAL V PRINT CLEARLY NEW:[ RENOVATION:( REPLACEMENT:I- PLANS SUBMITTED: YES[] NOD APPLIANCES 1 FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 " -- BOOSTER MIEN1111111111111•11111111111111111111111111111111111111111111111111111111 CONVERSION BURNER 111131111111` I1111 . COOK STOVE 1111111011111111111111111111111111111111111111110010,11111111111111 DIRECT VENT HEATER W`r DRYER 1,. ...- - 111111111111111 C(-) FIREPLACE I,�- .. ,INNIMEMUM.11111111111.1111111.111111111111 c URNACFRYOLATOR 1 1 f GENERATORIion INFRAREDaloolo IC) GRILLE IIIIIIINMINIR HEATER I( I I II_ I II, (--- �� �I MAKEUP AIR UNIT OVENOL HEATER .1M1i - i I �-- OVEN I�! Ill�' '�I ut • ROOM/SPACE HEATER Ellinli_II I ROOF TOP UNIT iI'lmII 'InI TEST UNIT HEATER ggialigunzionno, _ UNVENTED ROOM HEATER WATER HEATER �J OTHER 5111•11.11MR.111111=112.11.,M IR= - - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO D I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �-- LIABILITY INSURANCE POLICY [±.1 OTHER TYPE INDEMNITY [D BOND El t-- 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. 1:1-- CHECK ONE ONLY: OWNER D AGENT EJ 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 cornpli e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. p.46 ///J PLUMBER-GASFITTER NAME_STEPHEN A.WINSLOW- _ LICENSE# 12298 SIGNATURE SIGNATURE �L MP D MGF D JP D JGF 0 LPGI0 CORPORATION D# 3281C , „ PARTNERSHIP D# _ - .. .. LLC 0# _. _ COMPANY NAME: EF WINSLOW PLUMBING&HEATING _ _ ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 1 CELL NIA EMAIL accountspayable@efwinslow.com � ,OCT-, Vg //Pty- 5 p • may, �✓ phi{rs� A tOE. La,ssasObV16 PY L6Gb6a6 vJ 2rl atuu56LassWc841u Department of Industrial Accidents c = 1= Office of Investigations =, r 600 Washington Street MI.j.�, MA 02111 Boston, - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ` n Please Print Legibly - Name(Business/Organization/Individual): E.C•Wv 1- i ew Y 1U„��kvIc l Address: 3 �e'Awn _1rdQ Ok City/State/Zip: Sc,s kin Ycr is ,1-l., l4P Phone#: G5OS-391.-11'7 Are you an employer?Check the appropriate box: j I am a employer with °70 4. Type of project(required): ❑ 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.1 7. ❑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. ❑ We are a corporation and its 9 ill Building addition required.] officers have exercised their 10.❑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 12.❑Roof repairs q ] employees. [No workers' comp.insurance required.] 13.0 Other thy applicant that checks box#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. isurance Company Name: N.,i C U 0 J___; f n olicy#or Self-ins.Lic.#: \$a Expiration Date: (—0 — aG�. C. )b Site Address: 3 COnnr+‘cn W-2a-4h A CNe3 (,I � ,I City/State/Zip: b��LI b 7 .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a N 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 to at a copy of this statement may be forwarded to the Office of tvestigations the DIA'for insura overage verif a,on. `\ V do hereby certify un e e ains an/penalties orug that the information provided above is true and correct. �` inatu 1'� �� Date: (a) Q'i } ao� hone#: . %,n']r 777K -.NN ....-- I '''N\I\ 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#: