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HomeMy WebLinkAboutBLDP&G-20-002012 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Yeifuvf-t-kik,,,,,,„ et MA DATE) It'll/I'1 !PERMIT#/k_e_LV- o�� JOBSITE ADDRESS Nq (Apt(rickey-IZI 5, YRriehiA OWNER'S NAME` *tie Nera+404 1 POWNER ADDRESS 51EPP►[ TELpt y i?t 1 SI G 7 1 FAXI I TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIAL l.-- PRINT PLANS SUBMITTED: YES® NOD CLEARLY NEW:® RENOVATION:® REPLACEMENT:�— FIXTURES 1- FLOOR--' BSM 1 2 3 4 5 6 - 7 8 9 19 - -11 -42 - 13._. . _14__ BATHTUB PIN IIIII ( (•� - _ CROSS CONNECTION DEVICE NM DEDICATED SPECIAL WASTE SYSTEM maximmuiptan ,........ ...'; DEDICATED GAS/OILISAND SYSTEM ma aim I♦ mei mil 001 pm mg.(o MN NM MI MN DEDICATED GREASE SYSTEM OM WM PIM MINI NM MI.11111-11111111 MN MR 1�'N-WM OM DEDICATED-GRAY WATER SYSTEM NM MI _ IN NM u MI UN MI MPoat iimi Pm DEDICATED WATER•- ---- - - lin----- -.IPA DRINKING FOUNTAIN UM Mill dill sliNi ila um um mei on low um NO OM 111111 FOOD DISPOSER 11.11 IIIM lli.MIMI Mil On MI MOM MN OM WNM Mill IMO OM FLOOR/AREA DRAIN NM NM Ii WO iliiii MENN -- MN _ INTERCEPTOR(INTERIOR) Pm my ma mum um ini WM NM OW Mall MI 11.11 In LAVATORY EIRME"1-1 SHOWER STALL MEI Mil NM NM Mil W Mill MI IIIII r WMW Mil OW IIMMVEZMEMIUMEXCilliiiil S•SINK URINAL iii - NMI - - N MIN MNiNlRNM (♦ all nil M-WASHING MACHINE CONNECTION MN neil EN MINIM N. num us um imp wpm um MIN WM OM WATER HEATER ALL TYPES ■wIMME INN IMP MR MR SIM NMI 111111 IMO MN MUM NM MIN WATER PIPING NM 11.111 Ilin NMI I! MI WM NMIMIN M MIMI MI MilNs m OTHER -- - - - MIWM11111MNWMMNMO11•11MWMinINMMUM . 1.1111.1.111111_ MR MI Mill MIMI MIMI MI NM MI Mil Mil Nil NM MN MI MI INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY® BOND Ej 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. C0 CHECK ONE ONLY: OWNER © AGENT El `D SIGNATURE OF OWNER OR AGENT '5 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 pp Hance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. co Hance Cf-- PLUMBER'S NAME STEPHEN A.WINSLOW _ LICENSE#112298 I - SIGNATURE9 kit L MPO JP® CORPORATIOND#+3281C JPARTNERSHIPD#I 1LC €) I n- M COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS,8 REARDON CIRCLE 1 `r` CITY SOUTH YARMOUTH STATE MA ZIP 02664 1 TEL 1508-394-7778 I 2 FAX 508-394-8256 CELL N/A EMAIL account payable(c�efwinslow•com __ —� Pt' CA Z o 4'3 H a 0 -vo IFr3K 0 ( i t The Commonwealth of Massachusetts _*, 1, Department of Industrial Accidents : j 1 Congress Street,Suite 100 =�lc oe Boston,MA 02114-2017 www.mass.gov/dia \ Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ` NO Applicant Information Please Print Legibly ` Name (Business/Organization/Individual):E.F.WINSLOW PLUMBING &HEATING CO., INC v 0 8 REARDON CIRCLE Address: City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): LEI I 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. I]Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will airs or additions ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs proprietors with no employees. 12.0 Plumbing repairs or additions 5.1::I 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 6.0 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 information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY 1909A Ex iration Date:01/01/2020 Policy#or Self-ins.Lic.#: p 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 Ides of perjury that the information provided above is true and correct. if Si nature: , _ 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#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 04,2019 PERMIT# BLDG-20-00i 00' JOBSITE ADDRESS 49 CAPT CROCKER RD OWNER'S NAME RODGERS MARIAN L G OWNER ADDRESS 49 CAPT CROCKER RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL Ej PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF 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. 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: E F Winslow Plumbing&Heating ADDRESS. 8 Reardon,49 CITY S Yarmouth STATE MA ZIP 02664 TEL 5083947778 FAX CELL EMAIL accountspayablet7a efwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ FEE:$ PERMIT# PLAN REVIEW NOTES