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Home My WebLink AboutBldp-17-003662 • EVI AS-ACHIUSE TTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - ,+ _ CI I Y�-T 1 __ r r__ '_�--) 1 MA DATE 1_ I �'I 3 J I ,PERMIT? DP-/7 06 6IQ JOBSITEADDRESS j �(- � J�a 1 OWNER'SNAM0 +i: L r`C' 'W RI OWNER ADDRESS i TEL � � -411 AXI fi TYPE OR OCCUPANCY TYPE COMMERCIAL 17.i EDUCATIONAL f RESIDENTIAL EV . PRINT CLEARLY NEW:1J RENOVATION:IJ REPLACEMENT: PLANS SUBMITTED: YES L NO1+ FIXTURES 1. FLOOR-} 1 esm 12 I 3 I 4 1 5 1 6 1 7 I 8 1 s 113 111 1 12 1 13 1 14 BATHTUB II -._._¢I._ 'll----- 1L_ _11:711 `,IE•....'fi.. .__I ::TI._—(IL>= ._II__.l:U_.,_ tlL..11.--.,.t CROSS CONNECTION DEVICE IL L_._.:.. ----- 'FIT,1._ —T.. _..ti. gilt.._:_11__..._ _ '1 ..:-U l-----= lr�•. __Ii `► � _.:i DEDICATED SPECIAL WASTE SYSTEM II- -J----- [ ! I=l,:-_-,3E_'+I_r :MIL--•- -rI):_- I:-.. -'I---. DEDICATED GASIOILISAND SYSTEM L �:1-7I-_ II:: • filr1C.--.-1h._,p-:._ [7:1:7_.. �t�U:.:_: '.IL_--. ��_. DEDICATED GREASE SYSTEM IL..._. r.-:l. iil.-. . 1 .-�-1=1� ±I-__...3 -EIL_-__11. T-11-" Ti- I--Lill-___ _' 7 DEDICATED•GRAY WATER SYSTEM h_}I.....• :-.lIL-.:-.,.yL:_ �,_ s_,_ ._ I - ='II-.-:----:�IIG:._ ._.._1..=.-IT .i DEDICATED WATER RECYCLE SYSTEM -"�T— r : �.,_ _ ri i ,l DISHWASHER • 1-1^I,r 'r-Irk.• -}- ► ,, -.~.. -u I•_ L_.-._- DRINKING FOUNTAIN r:?I_ I =1_J _ r. '1 I -1 ._--`11 'll • I FOOD DISPOSER L—+IIY _ I.,_,~10A _ _ _ ®_ _ FLOOR I AREA DRAIN I,_,_:._'r_..._ I IL: _ �..-__{IL-__.=I.:,.n !,I. - p.-:-.III;! 1- d. . 'II-- ...T..- INTERCEPTOR(INTERIOR) 11..-.--.'a11:. • ,II,__ _d_ _A—a_ I,°f:_,.71 _ 1_ ir. L:,--:t KITCHEN SINK L . I__�I-- ll• - 'I_� I'� . ' -'ll.. ra .I-_, 11---'L.: `I_=.'- I - 00 LAVATORY 1ij[ �:_P1 ;JI. ,—11^,i''I_::._ . `li•. 11__ - [— `1—1,L-.'JL— ir` ROOF DRAIN L—_.!I ._r:._ . ��f ®I�®®�L--- ;MI SHOWER STALL i _ r i _A_,!'{ I- 1- __',' 4 •. • SERVICE I MOP SINK JI- -._ ETTA___ ]L__._Ji._,.-.._rile-' --_,L_:,_=,_ =L_- __. 1:__,,:.: TOILETi... I-'--...jI 'I .-- ' -- II ___ -_.. i t __J�___ , URINAL 1__._.. r. :L_, .-. 'L---4 I_�_��L !: -___-`sl 1..-',:.1IIL__.. L E`L_----: WASHING MACHINE CONNECTION ai . ;1 .._:1- _'--i1-�lt_,.>-'L -. ',1_...._l[�1-11, _..... [i-1. .• ••1-71 WATERHEATERALLTYPES li_ _ I_-_ q___ 1 1-1�-, . _)1�,_.,..jI__ .i,-- !L- •III= _--' .... I- ll-... -I WATER PIPING . "�- J _.. - -_,ill.. _ • .. Ii 1-.�!_.�� ... .-.. '-i.- - OTHER __ __ L_-- --- __.__.. .._,,„.•._._...._.l__:=•.::P. -11 __ -__:I .1. _ _ - ---.-._- ._......... . .. .P1 :.,�._:_:� .411 -.7i37 1'I--11..- s I. li ;L ;IL-_411I _II``II (--_------__---_----=-----�1.T.=3f-:_:_•l._ ,._--..-.7C__- ----1- ,1C=-�L_-�l-=:=. .[li_::,-''L=�-�1��IL..:_..:•�Il____ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Oh,142, YES 1L NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY L OTHER TYPE OF INDEMNITY LJ BOND la•• OWNER'S INSURANCE WAIVER:lam 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, (O - CHECK ONE ONLY:• OWNER AGENT I-�I 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 corn e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. :(1 -t PLUMBER'S NAME STEPHEN A,WINSLOW __ `1LICENSE# i 8 i SIGNATURE 0 MP D JPU CORPORA`IIONIA#13281G :PARTNERSHIP IIM- _•_.LLC1-1#1 COMPANY NAME EF WINSLOW PLUMBING&HEATING j ADDRESS I 8 REARDON CIRCLE CITY SOUTH YARM011 T H Il STA T E FE 1 ZIP.[02664 `1 EL 1508-394-7778 I , FAX 508 394-8256 I CELL L . � ILIA EMAIL accounts ayable@enyinslow,com ^� ^� er- `_gjJcn:e.-eofl Nutvomerxgsuma ' 600 Washington Street Boston,li.r A 02111 .."-.',,i---,jwww.mass.govldia Wobrker ° Coimpesisatio n Insurance Affidavit:En,„idlers/Contraetolrs ileetlrieians/Pli bers . ki Meant Information Please Print 1<egihiy [arlle(Business/Organizaf.on/Individual_): l-'rr.ti t;ri: OW5 t.104,1l7;v icl ��z tX- �q. �1-5 k0'tl,.e . . . 0 - l 1 4ddress: e it l[cr. -Q_, ... • 2,iiy/Stale/Zip: Sock{'': ,,,,,T n l'-k c Phone#: '..501.YIN-11 f are you an employer?Check the appropriate box:' Type of project(required): • •I am a employer with `7O 4, El am a general contactor and I 6. [New cons action % employees(full and/or part-time).'* have hired the sub-contactors Fl I am a sole proprietor or parker- listed on the attached sheet. 7. Remodeling . Ship and have no employees These sub-conftactors have 8. [Demolition - workinglforme hi any capacity. workers'comp.insurance. 9. 1 Building addition [No workers' comp.insurance 5. [ We are a corporation and its 10.[Elec7ical repairs or additions required] officers have exercised their L. 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 12,_Roof repairs insurance required.]t s employees.[No workers' 13.[]Other comp.insurance required.] ny applicant that checks box#I 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 tub-contractors and their workers'comp,policy information. Ira an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site formation. vi— surance Company Name: ; i'-4r J , 1.i•',`l,=Cs✓i .%,r\S`t;r i A.11 S2 0.1r,"„ V'1 dicy#or Self-ins,Lic.#: - 1 A - Expiration Date: c—j'' =TC31`7 b Site Address: S �C1_rir;r,\C�k_14'ti 0-:1�, kip e, A`J'1 ,1� �1 City/State/Zip: t i s ttach a copy of the workers'compensation policy declaration page(showing the policy number axed expiration date). lure to secure coverage as required under Section 25A of MOL c.152 can lead to the imposition of criminal penalties of a in up to$1,500.00 and/or one-year imprisonment,as well as civil penalties inthe form of a STOP WORK ORDER and a tine 'up to$250.00 a day against the violator. Be advised tbat acopy of this statement may be forwarded to the Office of ' vestigations of the DIA for insuran eloverage veri ation. f f , io hereby certify unic.e`rt,ie pains an7 penalises of p2irjuty that the information provided above is true and correct. • gnature•..• - / 4A °"..�_ Date: Va..i 3 t I J k t.% • tone t: k- i' >h`�Va•i 7X • Official use only. Do not write in this area,to be completed by city or town official. - City.or Town: Rermitil,icense= • . Issuing Authority(circle one): 1.Board of Health 2-.Building Department 3.City/Town Clerk 4.Electrical inspector 5.lplurnbinglnspector• 6.Other - Contact Person: - Phone#: MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK r.s.,.igr CITY _- MA DATE 1 IPERMITP / -/�/ — I—i �Gw JOBSITE ADDRESS I cD ' OWNER'S NAME 1 ' "?7• OWNER ADDRESS �7c•-- ,( .. •f IY1�rY r++7 `IEL) 'Ninai ______'"tFAn_ ,— _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL . RESIDENTIAL PRINT a '' NEW:EI RENOVATION:II REPLACEMENT: PLANS SUBMITTED: YES[ No 1 APPLIANCES T FLOORS-F BSM 1 2 3 4 5 _s 17 8 s 10 11 12 _13 14 BOILED. I ►1_.7.7.37711. _;!-I:--p-_4I _II. FI.-• •I! L..i••--I•I 11.--•---'- - -1 BOOSTER �I ~I I _ I I. .....11.. ~'.I-_ 'I ..i! _=11.. '.I I--.•1 -7 I !- ^ 11_.::-f l._. I. (7 tEr:, ..-7,-II:.- —"ia�: I. i!--. .:d li .Ili_=-_—iI---=i _.��1... .:}1--.---}I:_ CONVERSION BURNED. _._ __ __II_, -- COOKSTOVE I--:--- 14 �IIY-. il. ..-,.1.1 -1i.---.,.;I._........C._.�ll...-. 1. __ I. II 11 .1E. I DIRECT VENT HEATER T _ DRYER IL_- ;I._ 1�_�_117__ I,• -__j_= .rE_. `I-_ c -;�.-,1---z�.fl-- Iy,-_-:11r _.III;I FIREPLACE I-- - _^11- ,—!I. _t _ -- - =,i';- =•1—.... --,I 11 I FRYOLATOR • I,„ ..II 'Ii, 1 -_11. Jr. _.i1,_ 41 1�_W I. . ._II_----1- 1- ,,, ,II_ `i FURNACE I _- IH_---III -_- kl--_--_I I.-_4_,1 •.I~___%i�yll_ . `i_ . .1i_ -al 7,1l_._ .11 _ II GENERATOR 1- -_rl__ H�..- i :1. (? .i1_llE ti t!_ ____-l•i�_;.- . GRILLE {.:--�1! 117. ,a.l-_: l` . -I_ -_ 1" . l - ,i;;ti;I�_ 2-:1_ w_1i_ .--i!. iI. _1i_ _.i INFRARED HEATER - - ' _1__i• -•`1-.-_..iI_ - _.II_�-_ i. `III. 11 _,I -,,_i. _ i _I LABORATORY COCKS • 1 —..f I _ 1!._ L 1'_ }l 7, 7.7_I 1I -..._'I .. .1--:-i,1. — 1 —..1- .-. r Q MAKEUP AIR UNIT __ :--- � . L __ I-� 1 1_ __ 1 . I I! I._ _,1 ( �.. l,. i� Ei i1 'I,. lr it ._._ - - ._:_:_ :-._..- .:... : 1�:- OVEN IT11:...;►I.._...i!.-=::-11_... 11....--3'.-- . .'I.- .:;il�..,.fi1�---�-1I.-..V.}I:.:-._,11,.... `I"- ..'�p _.-1 I —'1,�.?I . ....il.. 1I. .-'.11 =..i;-_-_-3 _—'l._ .1�. 1 [ 1..; ;l CI, 1 - POOL HEATER _--. � � _ -. ... . . . ____ .. Cr P.00MISPACEHEATER !—,11 .___.11-._-.-.J!,,.._TE�_'!_,_,_tl.. .II-' 1-_.:, I_..._:I, I__..�_�1._._ I, J!_,-. •, ROOF TOP UNIT --IL. ►rT. H.. .-f1. `1 --� I.. . I_.... CI. . 1!.. _ I...._.. H_._. ..1®� __ -- __ - TEST 1 :1_, F. 11,_ .11. il. (1.. II t' 1. t�® i UNIT HEATER • 1 ...... .._ ._.L..YI,.. _ I . _,;,!,_.._ `i._ #1�:_ tl. . lil,.._=.1 . ..•`1 . 1!_ ..-® UNVENTEDROOMHEATER I .. __k.::...•1I..._{t_7.JI:_.,-:41..... iL._ _':----i "-:.:1'1.- 1,.. -- WATER HEATER- - _ -I a1,....,II .. 11u 11.... .1.1 -. . . 41�_;I. I:i ft. rit = _ . — l i. 1 i - OTHER -..rt . ._ _. I . J 1_ t 1 1I.T 1I 1- IR-`! 1I _ -_ _ iNINIE _ _ _ J , . : . I 2I `L- :1.-. 1 .. ...i„_ tljr.._it 'I--- :1i, _IH:: _1. ..._.®® _ INSURANCE C•OVERAGE 1 have a current iiabilit insurance policy or its substantial equivalent which meets the requirements of MGL,oh,142 YES ;NO El • 11F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY Li BOND DI - OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have theinsurance 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 U AGENT _ SIGNATURE OF OWNER OR AGENT Q I hereby certify that all of the details and information 1 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 ibis application will be In compl ce with all Pertinent provision of the 1 • Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ti PLUMBERGASFITTER NAME i 5 T EPHEN A,WINSLOW ___ II LICENSE 4l 12298 SIGNATURE MPU MGFI i JPE 1 JGFLi LPGIL_i CORPORATION1 J L3 81C 11PARTNERSHIPU L- _ i LLCI�ag ^s - COMPANY NAME;EF WINSLOW PLUMBING&HEATING - •ADDRESS 8 REARDON CIRCLE -- • - --1 • CITY I SOUTH YARMOUTH ` STATE MA ZIP 102 664 'ITEL bOs839^7778 FAX 508-394.8256�11 CELL _ iEMAILLaccountapayable@efwinslow,com r - - • . 3 a I. - ' SY' YYw JC/6ass.gOY/dia • Workers'Compensation Insurance Affidavit:&nniideres/Coot mctorW/Eleetlriciai s/Phu nberrg "' A plicant Information ]Please Print TL eg blv .- ' N. r = ) ' i Name(Business/Organization/Individual): c-A—• u i nsi ovJ ikt im.10 vei X.kl r.{, . (,-# i,�-}p 0 0 Address: g' ,Ro,f;)Y/i k_.x:"r_. . City/State/Zip:. So s'; Y c rs ,.F 1 -ki,` Phone#: F`S-y:(`r'7% . . Are you an employer?Check the appropriate box: Type of project(required): ,III am a employer with I O 4. ❑ I am a general contractor anal 6 [New construction employees(full and/or part-time).* have hired the sub-contractors ;,[] I am a sole proprietor or partner- listed on the attached sheet.I 7. [Remodeling ship and have no'employees These sub-contractors have o. [Demolition workingfor me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. C We are a corporation and its 10.[Electrical repairs or additions _required] officers have exercised their i.—I am a homeowner doing all work right of exemption per MGI, 11,[Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.[Roof repairs insurance required.]t- employees.[No workers' , _ comp.insurance required.] 13. Other my applicant that checks box ill 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 anew affidavit indicating such. ;ontraotors that checkthis box must attached an additional sheet showing the name of the sub-contractors andtheir workers'comp.policy information. . am an employer that is providing workers'compensation insurance formy employees. Below is thepolicy and job site [formation. 3 ` CT -• . tsurance Company Name: t al.),.0 �'kti kr it l°-J4 , ,,e1 (J\rck n ors 0t, -„ toN , .olicy#or Self-ins.Lic.#: li a i it - - - Expiration Date: [-•—H C71' ib SiteAddress:P-3 �' � c j 14'� : ' , le.3k l`O} (ri1i City/State/Zip: O,)2-4fd .ttach a copy of theworkers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MOL c.152 can lead to the imposition of criminal penalties of a fie 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 flip to$250.00 a da against the violator. Be advised at a copy of this statement maybe forwarded to the Office of Ives tigations roof the DIA for insurer veoverage ver c)ion. • do hereby certifj)w1(1.14e pains and penalties of(petjuiy that the information provided above is true and cignat(u.r.m•—_—_----,---), 7e orrect. � i i I/ , f .3 Date: , al 3 I 1 aottr hone#: .c( -•.�'�t\I, i7IX Official use only. Do not write in this area,to be completed by cic 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#:• •