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HomeMy WebLinkAboutBldp-17-006860 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '! ca,~c/`�LiVil RMIT#, P"/7-eZ) 6O ;..-`GI y, CITY t�rin�;/�� MA DATE I JOBSITE ADDRESS I V in 4 Ik ia.fA I OWNER'S NAME b'D1?Ja('4 ' �DS-' 1G2 2 PIir�� TEL TEL 4 i 1,1, /7 FAX P OWNER ADDRESS /i TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:D RENOVATION:0 REPLACEMENT:cg, PLANS SUBMITTED: YES D`NO. FIXTURES 1 FLOOR—► BSM •1 2 3 L 4 15 6 7 8 9 10 11 12 13 14 BATHTUB i _ CROSSCONNECTIONDEVICE ` _ r V-- ..._It. .. -, 1 _ . .it ,_ I _. DEDICATED GAS/OIL/SAND SYSTEM .11111 DEDICATED SPECIAL WASTE SYSTEM i �— �� I � ii DEDICATED GREASE SYSTEM DEDICATED'GRAY WATER SYSTEM ; , � DEDICATED WATER RECYCLE SYSTEM IN__•.__' , L ! 1 i DISHWASHER :- 'I - • ' si r, DRINKING FOUNTAIN � _ ,� FOOD DISPOSER I. ., r� _FLOORIAREADRAIN .Im— .,. INTERCEPTOR(INTERIOR) ',: ... ' KITCHEN SINK 4-- ' � Jj LAVATORY _ _ �, ROOF DRAIN 1 _ SHOWER STALL �R _G ,; SERVICE!MOP SINK rMuU! . i! ,. ! L—.r..,., ,. ,-': TOILET ` URINAL WASHING MACHINE CONNECTION ' ._®`I I i WATER HEATER ALL TYPES WATER PIPING 1 .1 it l a�=� I . OTHER i 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY[] OTHER TYPE OF INDEMNITY l 1 BOND 0 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 D SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details end information I have submitted or entered regarding this application are rue 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 pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /° PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 f C.u�` ��-�i SIGNATURE MP:3 JPD CORPORATIONI+ # 3281C IPARTNERSHIPO# LLCD#ME COMPANY NAME I EF WINSLOW PLUMBING&HEATING j ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH 1 STATE MA ZIP 102664 TEL 508-394-7778 . FAX 1508-394-8256 CELL N/A EMAIL Laccountspapple a©efwinslow.com Department of lndt&stria1 Acctaents ' __=�ii i1 �/ Office of Investigations f il'— 600 Washington Street ' _`,1_ Boston,MA 02111•S;')'irl>�,� IYw .mass gov/dia • Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please(� Print Legibly • Name(Business/Organization/Individual): E,C•W r�S t Ow Q(V��unct {•� 1 `�) I'n i Address: % ?oattn C:trt .4.� . a . - City/State/Zip: So s irh Yr'v^cs•--6" MA- Phone#: 50S- 3`14-1M?S! . Are you an employer?Check the appropriate box: Type of project(required): I am a employer with 70 4. 0 I am a general contractor and I 6 El New construction employees(full and/or part-time).* have hired the sub-contractors Remodeling 0 I am a sole proprietor or partner- listed on the attached sheet. 0 ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers' comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercisedtheir 1.0 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 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] \ny 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. Im an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1 (ormdtion. /n�� --_ (� isurance Company Name: l�'�YD•.+s CAv k S et�e- Vy olicy#or Self-ins.Lic.#: ‘5 rZ) . • ii,, Expiration Date: k--[ - aOi7 )1)Site Address:, 3 G m °"i A1/41-4I Cis ki City/State/Zip: b,Li to 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 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 a:ainst the violator. Be advised i at a copy of this statement may be forwarded to the Office of • ivestigations ' the DIA for insurapeeloverage veril on. i do hereby certify u it •e airs an;penalties o jury that the information provided above is true and correct. Date: l'ot 1 aok kin = i!- — hone#: .StIY,•214. 7 77X 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#: • A` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ^Gi= CITY 1�070 f MA DATE�/(/, 5/ PERMIT# P-/7-OO BPS D JOBSITE ADDRESS /y. /7/4g I(J/(JqY OWNER'S NAME di'.iyI h 3 G OWNER ADDRESS ,KJ f- /_>}A wTy TEL , 247 . 1•f IFAXo 1 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL ,.j PRINT CLEARLY NEW:E1 RENOVATION:D REPLACEMENT:94 PLANS SUBMITTED: YESD NO I'` V _APPLIANCES 1 FLOORS-► BSM 1 2 3 4 5 .6 17 8 9 I 13 14 BOILER 1 _._ 'l I _i - 1 . .._ I _. i � .,. -A- .. �, CONVERSION BURNER ��__ _ _ .r1.. .:1 _,_( �����_ I. BOOSTER 33 ,fay -.,.i,,,•.,,.� ___ _- ' t •• COOK STOVE ` 'I. . . r 1MI _.. DRYER VENT HEATER �I _�I �r t,�- l r I. I1111211% - . I �� FIREPLACE ___t i- 1, SIM -._i.-_._. .. ..-} I. ' FRYOLATOR FURNACE !4. - _ -- - - -i -- ' --1---1.. t i I . V GENERATOR -. w GRILLE I I `! • I _�7 -i -I INFRARED HEATER _._ .�1 -,1 A _y _— '' ----- e ..—_I I - ' 'mI V _. I ..LABORATORY COCKS :I, '�.- . .,i. , •• MAKEUP AIR UNIT i' .._-_.1 . I ,�..,._ ,..._.... _OVEN _.i i .�1,1" z.. _ _I ' -- ; POOL HEATER ..- . —1 ! r + m., EI f f 1 r .111111t-,frL ROOM 1 SPACE HEATER � � _ _ -- � _ � :�' .'_-. .E. ROOF TOP UNIT L. i ' t t . r \; TEST I _ a,o.�UNIT �� UNVENTED ROOM HEATER � I -�I ��as �___-_ � I• , : iislom . . inim WATER EATER � �_� _ IMM M - OTHER � � •-- - -----_.._++-- ..- -:':t.'�C:ligittioniiitior - _ --- • Lllookiiitink .._ ._ .. e INSURANCE COVERAGE I have a current liability insurance policy•or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY El BOND 0 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 D 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 compile ce with all Pertinent provision of the • Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 77-191 .4 / PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE# 12298 SIGNATURE MP El MGF D JP El JGF 0 LPG!® CORPORATION E#[MI_i PARTNERSHIP 0#I.LLC D#MI COMPANY NAME: EF WINSLOW PLUMBING&HEATING 'ADDRESS 8 REARDON CIRCLE CITY SOUTHYARMOUTH ? STATE MA ZIP1.02664 JTEL 508-394-7778 FAX 508-394-8256 'i CELL NiA ;;EMAIL accountsayable@efwinslow.com ' i= Office o•f Investigations �'K j= Boston' 600 Washington Street ,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers A licant Information • Please Print Le 'b ` �va21 snes/Organizationndividual): 1 ��.W i �$ p Ylk b;nz 2,_ �a� d. kit.$t Address: Ke o-rt i rtie.- 2,ity/State/Zip: Soy,-v\ r„--,c,,,-t•, r{A. Phone#: '508. 399-11'7 3j kre you an employer?Check the appropriate box: tI am a employer with "�0 4. ❑ I am a general contractor and I T'pe of project(required): • employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 0 I am a sole proprietor or partner- listed on the attached sheet.t 7• 0 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. 0 We are a corporation and its 9' ❑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 12.0 Roof repairs q ] employees.[No workers' comp.insurance required.] 13 ❑Other ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. mtractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. tin an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. surance Company Name: Pirtrai (" o -U0-A �N ,,t Cad dicy#or Self-ins.Lic.#: 13 I A . Expiration Date: c—1 — D.01-1 b Site Address:a3 M�v'?ca l•1 A, C g NI City/State/Zip: 0,-)W 6 7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). dlure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ie 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 'up to$250.00 a da a ainst the violator. Be advised at a copy of this statement may be forwarded to the Office of vestigations the DIA for insura eeoverage veri Ca on. / lo hereby certify un a ee ains and penalties o p jury that the information provided above is true and correct. gnat&i, d Gt., (AA/ Date: (a) 3I ) aot lone#: S7)g•35'1- 7 77X 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#: