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HomeMy WebLinkAboutBldp-19-006415 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING HVUKFl lit.—_11. L. z' t� PERMIT# �, �y,�/�I'�/� �y�� - ffl-" CITY / LY '( i i \ni 5-t ) I MA DATE' t 17 / 1 IJ` " c t"[" c_. j ` OWNER'S NAME j JOBSITE ADDRESS l 5 ) _ 57- (�-y--i �)I�_ N OWNER ADDRESS - , 't TELI. 1IFAXL I `-'f5 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL _ RESIDENTIALQ- PRINT PLANS SUBMITTED: YES 0 NOO CLEARLY NEW:0 RENOVATION:El REPLACEMENT:El 1 2 3 4 FIXTURES 7 FLOOR-4 BSM 5 6 7 8 9 10 11 12 13 14 - - - - - - - BATHTUB __-- _ CROSS CONNECTION DEVICE ----- DEDICATED SPECIAL WASTE SYSTEM —� �,�I---- DEDICATED GAS/OILISAND SYSTEM i I---- -- ---- ! -' - -- DEDICATED GREASE SYSTEM �� � — -.-_- DEDICATED'GRAYWATERSYSTEM _,_ Milk DEDICATED WATER RECYCLE SYSTEM _ I 1 DRINKING FOUNTAIINN DISHWASHER ,.............., _ _ _,______ _ _i _ . � FOOD DISPOSER r FLOOR/AREA DRAIN KITCHEN SINK INTERCEPTOR(INTERIOR) I --- _ _, LAVATORY - !— -I _._ _ . - ----__ __ _ . _ - -_ _ .- SHOWER SIN --- ` I, SERVICE I MOP SINK TOILET BIB - URINAL ._, iii, - I WASHING MACHINE CONNECTION WATER HEII= ., , , , ATETTT:1i1::: 11: U-- . WATER PIPING 1111111 OTHER _ _ , ,_ r- , r -.• .. • 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 LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El BOND 0 C-N OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the ;y) Massachusetts General Laws,and that my signature on this permit application waives this requirement. I CHECK ONE ONLY: OWNER 0 AGENT El C 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 co !lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE#1 12298_ -_ SIGNATURE MPEI JP El CORPORATIONO# 3281C PARTNERSHIP©#Inn LLC:II ___ I COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 18 REARDON CIRCLE _ ___. _____I CITY SOUTH YARMOUTH `STATE MA ZIP 02664_ ____ TEL 508-394-7778 -T-_,_^ ^__1 FAX 508394 8256 CELL N/A EMAIL accountspayable@efwinslow.com -_._-_____.-_____...______._.._-____-_--.___ $ 6.0 ,C ° PIO m...J1\ a Is.. ¢...4///66/64./YBIY6•1666I6 Vj 11d 66S./I6y/6/4aDL66a9 N. elrartnaenP of �!l, Industrial Accidents =_ ou= • Office of Investigations _ 600Washington Streetr " il—= Boston, A02111 www.tnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 1 licant Information Please Print Le °bl me(Business/Organization/Individual): E•c.w I nS I a dress: °awl %sae_ . y/State/Zip: cu .-K.J-in miir Phone#: 33.399 J'i'7 Si you an employer?Check the appropriate box: I am a employer with -70 4. [1] I am a general contractor and I Type of project(required): employees(full and/or part-time).*.* have hired the sub-contractors6. El New I am a sole proprietor or partner- listed on the attached sheet.$ ? ❑Remodeli g chon ship and have no employees These sub-contractors have working for me in any capacity, workers'comp.i 8 ❑Demolition [No workers'comp.insurance 5. ❑ We are P Insurance. 9 Building addition required.] officers have exercised their a corporation and its 10.❑Electrical 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 required.]f 152, §1(4),and we have no 12.0 Roof repairs employees. [No workers' comp.insurance required.] 13.0 Other plicant that checks box#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. z employer that is providing workers'compensation insurance for my employees. Below is the policy and job site xtion. ce Company Name: (-w U t -rI,PCNItt/1 ✓1 i or Self-ins.Lic.#: 1 $a I A • Expiration Date:j _ 1— aji Address:a3 clrrInAcvel k,`e0141-1 Cif City/State/Zip: O a copy of the workers'compensation policy declaration page showing the policy number and xpiration date). to secure coverage as required under Section 25A of MGL c S 2 can lead to the imposition of criminal penalties of a im os 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 p $250.00 a day against the violator. Be advised t i at a copy of this statement may be forwarded to the Office of ations • the DIA''or insurar•- •overage veri j on. 'by certify un e e ains a 1 penalties o •�u f fry that the information provided above is true and correct. i/. . _� Date: i 1 i aaoi• 4' --n78 al use only. Do not write in this area,to be completed by city or town official • ir Town: • • Permit/License# g Authority(circle one): rd of Health 2.Building Department 3.Ci • er tytrown Clerk 4.Electrical Inspector 5.Plumbing Inspector Q ct Person: • �` Phone#: �= MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i".ff r MA DATE,Si,l'J 'PERMIT# &�?Jw• ..a;,�i=9� CITY \/�I._I�C`�.�__i_:_t. _. �_._'_aL`_{w'�"���_ .'� _.� _I_ /� . y,, I 1‘,.__five , . rick.._._.._..i.Ii''_.._._- .G JOBSITE ADDRESS LSE__`-.` f=..f'a-�..i�...�,,t _OWNER'S NAME _- E"C",f OWNER ADDRESS _1.i_(llJ:'i; __ ^ (-"G I l� f 1f:,T,' TE4k.I. .rid- -_`,icq 1F - - TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL D RESIDENTIAL[4.— PRINT CLEARLY NEW:El RENOVATION:0 REPLACEMENT:L --' PLANS SUBMITTED: YES[] NO APPLIANCES 1 FLOORS--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER '_ -. __.. CONVERSION BURNER I.-, . 1 - I_ ._-_ . 1 . I- 1 _ - _ - COOK STOVE MIMI L _ I I, _ -- - I (D DIRECT VENT HEATER - - --- 1 - _ L I - = 1- .- DRYER 1-____- Imir __ ' tr.) _- -- ,! FRYOLATOR I_.___ _ I a FURNACE ( -_ L GENERATOR migin. GRILLE INFRARED HEATER _ _) LABORATORY COCKS 111.111MMININIIIIIIIIIII®W ®IIIIII ®11111 MAKEUP AIR UNIT I111111il ] 1 1111lll111111lIN[ L 0 - I I�I�®�� � OVEN ���h1I�1`��I�ll�l�111��i�1���®����I 11111 � ROOM/SPACE HEATER �I E ��' M POOL HEATER �i�(�[�I�i��l ROOF TOP UNIT .ill .._. 1 . , I®I; IMO UNIT __ UNIT HEATER l I __ -- I. _ lam, UNVENTED ROOM HEATER WATER HEATER MI®! M® MINI NM - ,Iti�®Imi�I®I� lI �I—®�moI a OTHER JI [ iI I II I[ f If If l -J'1 -�1___lam _,___-__1 L J_ _ WW1. ! - NM twoirs,...s 1101011111111111 lig En MN EMI INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [E OTHER TYPE INDEMNITY D BOND D i 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. L-) .. CHECK ONE ONLY: OWNER 0 AGENT [l 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 ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4,— L%'C.�P.ie—) -- PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW _ LICENSE# 12298 . - SIGNATURE MP E MGF D JP D JGF D LPGI D CORPORATION Q# 3281C_ ._. PARTNERSHIPD#. _. LLC[]#I_ _ COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE . ... CITY SOUTH YARMOUTH STATE MA _ ZIP 02664 TEL 508-394-7778 FAXL508-394-8256, I CELL NIA EMAIL STATE J5v, y Mlif • SEIA A 164 L1L/1l61l&i/16I✓L666616 tr..,1Id66y4y666.6666.1.661-9 Department O a nl P f Industrial Accidents "� h Office of "AA1_ �f Investigations .,E:�� 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): Vv•�. trk51 Ow ���p b'��` { l Address: 5 (&e C lt.2 (J City/State/Zip: c,s-c-in cro,,c3„ti,, MA- Phone#: 5508- 3 1-1'1' Are you an employer?Check the appropriate box: 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.I 7. ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity, workers'comp.insurance. 8. 0 Demolition [No workers' comp.insurance • 5. 0 We are a corporation and its 9 El Building addition 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 insurance required.]t employees. 12.0Roof repairs [No workers' comp.insurance required.] 13.0 Other kny applicant that checks box#f 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. tsurance Company Name: v w ;`� 1-1,>C)1 4 f C,rCil,.� . olicy#or Self-ins.Lic.#: is a l A Expiration Date: (~1 — ao a,0 )b Site Address:,D3 G.I'Anr\er1 -ec5k•R ae` +, ,( City/State/Zip: 0��L-1 07 .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 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 t at a copy of this statement may be forwarded to the Office of tvestigations the DIA.or insuraper-overage verif a on. N do hereby certify un e e ains an/penalties o cr jury that the information provided above is true and correct. N. i_ attic . laf . -'`. Date: (a) 3 i l ao ig- hone#: ki, 777g Official use only. Do not write in this area,to be completed by city or town official. 0 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#: .t