Loading...
HomeMy WebLinkAboutP-20-2418 , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK —,1 i'L- MA DATE 2 4 PERMIT#/ �ol;f-a- CITY��tllt22d��1. ---._... .. ... _� �__.��� �.`l.._ .1 z_ JOBSITE ADDRESSl6.ivokrit Imo/_ Amodiji prA OWNER'S NAME 1 ikhec i-- g 1 tig_ .e 2-- GOWNER ADDRESS __., . TEL1,5 3 .1[XO. ..jFAXilinillal TYPE OR OCCUPANCY TYPE COMMERCIAL( EDUCATIONAL 0 RESIDENTIAL PRINT CLAY NEW: . RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES 0 NOD �,_ I 13 14 APPLIANCES-1- FLOORS-} BSM 1 2 l 3 4 5 6 7 8 9 10 11 12 1 13 4 BOILER �-' IMP���)II---• �`�MI BOOSTER lol l l� i ®��®j ILMI I 1 n CONVERSION BURNER MINIIIMMOWMPOIMMMINIIWWWISIN COOK STOVE DIRECT CA I_ W lMILM � L FURNACEFIREPLACE ... F.1:1=5..._2_1 .._ . .==nollem .. ._. antout outtompeolOLM Might GENERATOR iii-r-iir.1,1‘iiiitWunittialltilliMILMINiiim on INFRARED HEATER MPIBMI 1111111 MO IMIMM LABORATORY COCKS -N-NUILIWI MIN*Wm Wil mow MAKEUP AIR UNIT �M�� «l® �� L� I J� :-OVEN il I 1 . __ . . i_.. . ROOM I SPACE HEATER ® �-- ^, j)�! -J TEST 111111111* I��� II UNVENTED ROOM HEATER UNIT HEATER 31111. •--In • � �a I. i � i OTHERR HEATER �._______ _ _____, 1,1 lumet+V__. . .._ ._ _ ®�� w ;--- l y INSURANCE COVERAGE I have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL.Ch,142 YES Ei NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY .✓I OTHER TYPE INDEMNITY[l BOND 0 ,p •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 true 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 compll a with all Pertinent provision of.he /r.' •Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME STEPHEN A.WINSLOW . .._•_ , ,I LICENSE#.12206._ SIGNATURE T- 7- MP E] MGF 0 JP 0 JGF 0 LPGI0 CORPORATION D#13281 C_. . I PARTNERSHIP D#j i _ _ - I LLC 0# 111111. - `-j� COMPANY NAME•,I EF WINSLOW PLUMBING&HEATING ---_I ADDRESS I 8 REARDON CIRCLE CITY I SOUTHYARMOUTH, • _ ..____ _... _...�,1 STATE MA'ZIP 102664 , .ITEL 1508-894-7778. , i FAX 508-394-8256 CELLI NIA , ... 'EMAIL'accountspayable@efwinslow.com . .._ .. .. • 3 The Commonwealth of Massachusetts -- ' Department of Industrial Accidents 1 1 Congress Street,Suite 100 c _�{=• $ Boston,MA 02114-2017 s ,i 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 City/State/Zip:SOUTH YARMOUTH, MA 02664 phone#:508-394-7778 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. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working_ for me in 8. D Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I 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 my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.t ❑ p 6.1:1 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. tContractors 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 Policy#or Self-ins.Lic.#:1909A Expiration Date:01/01/2020 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 [ties of perjury that the information provided above is true and correct Signature: /F/-° __ ��`� Date: Phone#:508-394-7778 Official use only. Do not write in this area,to be completed bycityor town official.f.� Y P .f.� 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#: r F IIAASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _,v�t_-y CITY I Y�rma��, I MA DATE! in L`z3/14 IPERMIT#/�� JOBSITE ADDRESS IcA Lookotl t' Rd Ya/09c 89/00/1 I OWNER'S NAMEI gobcri— RocJfi 9 lied P OWNER ADDRESS I ';at' I TELI51 j 75 90 6 0 IFAXI TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ❑ RESIDENTIALI �� PRINT CLEARLY NEW:® RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES® NOD FIXTURES 7 FLOOR--} BSM 1 2 3 4 5 6_ 7 8 9 19 --11 ,42 - .-13._ . .14__ BATHTUB - MI MN NM I• MN iNMNMNM 11111. CROSS CONNECTION DEVICE Mg.EWER- E N EDEDICATED SPECIAL WASTE SYSTEMDEDICATED GASIOILISAND SYSTEM KERN RaMMMana- DEDICATED GREASE SYSTEM _ DEDICATED'GRAY WATER SYSTEM - - --- ------- DEDICATED WATER RECYCLE SYSTEM .. DISHWASHER — - 3 N IIIIII DRINKING FOUNTAIN = i� I -� FOOD DISPOSER FLOOP.IAfZEP.EA DRAIP! L _ 5-- -E E M 4 INTERCEPTOR(INTERIOR) NM NM NM NM M MI 11111111 N 111111111111.1-MO KITCHEN SINK . = ma lMI _pm e um LAVATORY 111 um ROOF DRAIN Ell MIMIi ON WM ii.MPt - _ SHOWER STALL _ ilili leillii. OM illii MR M iiiit M MN SERVICE/MOP SINK inalii TOILET ILMIMEXXXIII. 5.=011. URINAL n . _ _ _____ ___ _ - -WASHING MACHINECONNEGTION --- _ IE WATER HEATER ALL TYPES XIII M- WATER PIPING ERUIR_ URI1 I _ _ _ _ __ __ _ _ ill.11 lilil .111111 W11°- MI MN IIIMMI_ Mill OM MEN MI MI 111111,111111111 IRE MIN MIN MI Illin MN MN MEM OM INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND D OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the p' Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER© 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 true 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 compl' c wit all Pertinent prdvision of the ^-- ArTh Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE#112298 I,- - SI ATURE — -3— MPD JP® CORPORATIOND#I3281C IPARTNERSHIPD#I 1LLC 34 s " COMPANY NAMEI EF WINSLOW PLUMBING&HEATING I ADDRESS)8 REARDON CIRCLE . CITY'SOUTH YARMOUTH I STATE MA ZIP L.q64 TEL 1508-394-7778 FAX 1508-394-8256 I CELL N/A EMAIL I accountspayablePefwinslow_com _ _ - - -- . 3 i 1 The Commonwealth of Massachusetts 1 i � ,l' Department of Industrial Accidents Well Il•.....4—. 1 Congress Street,Suite 100 f 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 City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): i.0 I am a employer with 88 employees(full and/or part-time).* 7. l New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. Ill Demolition 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[]Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.n Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 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. tContractors 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 Policy#or Self-ins.Lie.#:1909A Expiration Date:01/01/2020 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 Th,kk. 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and a pai s ndpen lties of perjury that the information provided above is true and correct. Si ature: "_ Date: Phone#:508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. 't,...7.....% S 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#: