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HomeMy WebLinkAboutBldp-19-005927 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFOKlvl a'LUtV bilmv vvvnro - - i PERMIT# 12ENf -�' met: �61f=.6 CITY rn �' 1 a. _ MA DATE�_.I _k j Jl JOBSITE ADDRESS 1.-4 '} C s iii___ OWNERS NAME pOWNER ADDRESS 6 i SiY1ltY',.JCS . I�`i,d-ni 1 t 51 TEL ` - FAX_ TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL I i! RESIDENTIAL PRINT PLANS SUBMITTED:YES-�-NOD NEW:0RENOVATION: .:. REPLACEMENT;[CV FIXTURES 1 FLOOR—; BSM 1 2 3 4 5 6 I 7 8 9 10 I 11 12 13 14 BATHTUB MIMI* 1110MEME NI IN - IIII — CROSS CONNECTION DEVICE ®®11.110 DEDICATED SPECIAL WASTE SYSTEM 1 _ _ 11 I 1 mipui Am, _ DEDICATED GASIOILISAND SYSTEM c DEDICATED GREASE SYSTEM MUNN NM III 111111 0111.,®� IIIII ION r ligilWi mum®'I®.®®iu! DEDICATED WATERSYSTEM RECYCLED411 DEDICATED GRAY WATER inewiinniligiminum NE liuM - - ." DISHWASHER - -_. ..MB wpm gm u; ill __ -- DRINKING FOUNTAIN � -'�,,_ ® I� '�®I®? 1- '_-._._ FOOD DISPOSER I_—i I - -. I I --' -_ u -- -- FLOOR I AREA DRAIN - INTERCEPTOR(INTERIOR) IIMEMIMIE ' ®ommiont KITCHEN SINK ®®,®®®MI --' LAVATORY 1,—ROOF DRAIN �', �M ..I._ . ._.` SHOWER STALL nit1. ._ SERVICE I MOP SINK _._-- MEMEM Ilimiiii. ITIIIII®MN® -_ TOILET ®!®Mil .NM® I® URINAL CONNECTION I fman, WASHING MACHINE _ un WATER HEATER ALL TYPES iill WATER PIPING MO I IIIIIhINui _�_T _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES O NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW C) LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY 0 BOND[_l 1 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the `T Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [., AGENT 0 n--- 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 nd 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. a-al b PLUMBER'S NAME I_STEPHEN A_WINSLOW_-__.__ __ _.°LICENSE#L12298r SIGNATURE MPO JP El CORPORATION:# 3281C __PARTNERSHIP:#E _ ___.___ILLC0#I_____. 1 COMPANY NAME EF WINSLOVV PLUMBING&HEATING 1 ADDRESS 18 REARDON CIRCLE I CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 1508-394-7778 _v._ ___I FAX 508-394-8256 CELL N/A _ EMAIL accountspayable@efwinslow coin 01 3 eVa-'� AMt. Q.Q/40bGb bVlD b Vd MV46bbb VIy z 1IA66✓✓h , bb✓ybb✓ C / 1epartnaent of Industrial Accidents ;�I Office of Investigations Washington 60 a `= 0 g I�'- n ton Street Boston,)L4 02111 www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/_Contractors/Electricians/Plumbers licant Information Please Print Le °IA Ile(Business/Organization/Individual): E•C..W irtS OW cress: Q cdar1 `2,t� r/State/Zip: cs i441 v`„osAin M Phone#: J3-399,117c ,ou an employer?Check the appropriate box: I am a employer with '70 4. 0 I am a general contractor and I Type of project(required): employees(full and/or pa . have hired the sub-contractors 7. ❑Remodeling I am a sole proprietor orpartner- 6. ❑New construction listed on the attached sheet.$ship and have no employees These sub-contractors have working for me in any capacity. workers'comp.insurance. 8' ❑Demolition [No workers'comp.insurance 5. 0 We are a corporation and its 9 ❑Building addition cal repairs or additions required.] officers have exercised their myselI am a homeowner doing all work right of exemption per MGL 111.❑Plumbing repairs or additions myself.[No workers'comp. c. 152 fc workers' r t 152, §1(4),and we have no 12.❑Roof repairs employees.[No workers' comp.insurance required.] 13.0Other )licant that checks boic III must also fill out the section below showing their workers'compensation policy information. wners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Ilion. 3e Company Name: y 641-1 `or Self-ins.Lic.#: 1$a I A' L y Expiration Date; lo4' _ a_0 Address:a3 Gnnr+xm kg-e6-1 1'1 AO-2 ae (iy 11 City/State/Zip: O�t j{c a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 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 fine $250.00 a da against the violator. Be advised teat a copy of this statement may be forwarded to the Office of ttions . the DIA'for insur.r' ;overage veri on. 'by certify un e e ains a anal-r p ury that the information provided above is true and correct. r j�� Date: (a i aoi' , al use only. Do not write in this area,to be completed by city or town official. r Town: • g Authority(circle one): Permit/License# \\.' rd of Health 2.Building Department 3.City/Town \. er Clerk 4.Electrical Inspector 5.Plumbing Inspector ct Person: • Phone#: ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _ , �i may, e� Ojt f ( l ieJ`-). ; MA DATE J4/11-/l q PERMIT#,Db/V3 nlf OFF CITY `1 l`(iC�i 2. .�a JOBSITEADDRESS 1`{_ 4CCX7t(Ica. _i_IZ_ _ _._ OWNER'S NAME rifra r c r,f-,(`-,_ C(ic_,/__ G �'k TE ?FAX ... _ ! OWNER ADDRESS 4 J -_ . l:_l �. �GI. ' `?r�.rm �,1,. '.. _ �,?C -. i-51(�a TYPE OR r -�'1 i PRINT OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL D RESIDENTIAL[- CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:I PLANS SUBMITTED: YESD NOD APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 .1 _ BOOSTER t _ I__. 1L U LI_ II _ U. l 1 1 4 1 1- 0 0 l I 0 Cta CONVERSION BURNER II 1j.= 0 1 L 1 COOK STOVE . 11 N I I ---.4► DIRECT VENT HEATER _._ .___ . I, , _ DRYER - . II I _. . _ � . _FIREPLACE ! � � I 0FRYOLATOR 1 I �, FURNACE II 1 `- -GENERATOR I I I . I, GRILLE 'L . _ INFRARED HEATER _._. , 11 ` L I LABORATORY COCKS _ . 1. L I CiMAKEUP AIR UNIT 'I .._ �L 1 _OVEN . POOL HEATER H . ROOM I SPACE HEATER ] - ROOF TOP UNIT i I j TEST I. _ --. I I 1. UNIT HEATER j I , I UNVENTED ROOM HEATER I WATER HEATER 1. d_.. I 1,1.. , ,I � 1_ _ � � I OTHER ) IL_ .. �I .v.- . ._ I®�,Irr.. �_:. l I I_ U �I 11. li 1`— i I I f- I_ i I I _ I I _ __ 1. �y lj -4 Li i ' INSURANCE COVERAGE - '` J I have a current liability insurance policy or its substantial equivalent which meets the requirements ofiMGL.Ch.142 YES 0 NO Q U'—' I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY to OTHER TYPE INDEMNITY El 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. 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.r e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME_STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP D MGF ID JP 0 JGF Q LPGI❑ CORPORATION D# 3281C PARTNERSHIP D# LLC D# 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 accountspayable@efwinslow.com .24A A UK. V YIl4l16Vl8rYLK8618 VJ.LI8bJU166.1884J6.66.i �• a �' l Department of Industrial Accidents ' 1 '�Mi= Office o • _ r_ .ff f Investigations =._ III 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E,C• Address: e�cvi I Q.- 0 City/State/Zip: ou - ar-o,K,,,(-,1 rk j- Phone#: "SOS- 394-7 77 Are you an employer?Check the appropriate box: Type of project(required): I I am a employer with � 4.� ❑ I am a general contractor employees(full and/or part-time).* have hired thesub-contractor ds • 6. ❑New construction :.❑ I am a sole proprietor or partner- listed on the attached sheet.I 7. ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers' comp.insurance. 9. Demolition [No workers' comp.insurance • 5. ❑ We are a corporation and its 9 ❑Building addition ❑ required.] officers have exercised their 10.111Electrical 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 insurance required.]t employees.[No workers' 12.❑Roof repairs comp.insurance required.] 13 ❑ Other 1ny 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 tformation. tsurance Company Name: �y MQ1.1.1CLA . vi olicy#or Self-ins.Lic.#: 1 7. I A Expiration Date: (—[ — ao a 0 )1)Site Address:‘)3 Co-rv,mc„n 1/4,...e e,_,( Ad-e Cte, .ttach a copy of the workers'compensation policydeclaration '�I� City/State/Zip: d��c-}(�'� 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 teat a copy of this statement may be forwarded to the Office of tvestigations I the DIA for insura •- 'overage verif .r on. do hereby certify un e e airs an'penalties o jury that the information provided above is true and correct. i.natu? : A l _IL_ q Date: (a 3 i 1 a©t 'N hone#: '{, 7 77g 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#: