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Home My WebLink AboutBldp-18-005220 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK _H;• -1�,- ,� , ,y► ,-IfOTZ-1 MA DATE 3 `)' S PERMIT#F CITY - JOBSITE ADDRESS Lf(x71"9'//U s%2 �� OWNER'S NAME �O L L'ill/� , OWNER ADDRESS „.� 6 - l TEL 6i2 3 7S/o`./.2-1/1 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL c EDUCATIONAL J RESIDENTIAL Pr- PRINT PLANS SUBMITTED: YES 0NO[ CLEARLY NEW:( RENOVATION:L-T REPLACEMENT:Er FIXTURES? FLOOR BSA AI..._�_- 1.-2___I _--11 4.:_1=L6A1(Y_- __ L_..9 1__0 �11 it 12 ., __ y.l.-14-a BATHTUB I— s I. CROSS CONNECTION DEVICE jO! I_ _. .._I __ 1. _ . I r L:.._: -il__-_ L .�1 ; DEDICATED SPECIAL WASTE SYSTEM 1_ iI--__.I__--__ I_ II: I, - 1 I _DEDICATED GAS/OIL/SAND SYSTEM r II I-.__ ,I r--- 11 1 tr L {- DEDICATED GREASE SYSTEM I I. r� i II_ = 1 DEDICATED GRAY WATER SYSTEM fl-1 �1_. __r ___r-�_I ' -- 11 _. ,. L 'r 1r I I __ 1 'sL = DEDICATED WATER RECYCLE SYSTEM I 1r_^- r- 1 C _ 7111 1 -= 1 Imo- I____. 1 -- 1 -i 1 1-,-. 1 DISHWASHER I �_ - L- �_ r -1 DRINKING FOUNTAIN �1- = 1 r r �1_,I L 1) -771 FOOD DISPOSER (- i.. I .- r I $ I „_ I� ..._ FLOOR I AREA DRAIN I - _, 1-- .-,i�__ L_ I _ rw I I r_E I _I CHENINTERCEPTORSINK(INTERIOR) (----'�—I1 1:_-- I +I --_-_1=-1t _.l -_ ► L 11 1 E _1 ..L L_ .I_- _ -- -:_il _. L. it f��f r77 Ml KITCHEN I ,1 [� :I I -I_ r r Ii. _.JL. --' r LAVATORY __-Th I I 1 r : 1 1 I-._.._ SROOF DRAIN HOWER STALL 1 1�- -h 1:. _ 1 f (- 'I 1 �11 : r-:'=1 SERVICE/MOP SINK I __ L I ._ _ 1 -I ,,` f-= ,1___ . -_[- 11_,. �I lr-�, d) - I1- 11 11-_-'L _ I Q--- 'f= f - _.I f TOILET ��1- 1- 1 .: URINAL WASHING MACHINE CONNECTION 1_—•1 -'I , II.:_ _F ' r- I �' '�-'L- 1 --11 I WATER HEATER ALL TYPESI 1 - __ ---- 1 -- I {I it 1[ - 1 �[ .1J 7 WATER PIPING =11 1 I -71 L ,I I f �. OTHER -� _ ,1--' :_ - _ L.-- I I~ .�Iw� l 1 'L _ r r r_ ,I I � -`'� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES P[�: NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 11 OTHER TYPE OF INDEMNITY EJ BOND L3 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 ki SIGNATURE OF OWNER OR AGENT I hereby all plumbing that all of the and etails and information I have installat installations performed under he'tted or permit issueddfor this applicationg this n will be inplication re co true lianceand accurate to the with all Pertinent provision on of the and sa p Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOWLICENSE# 12298 SIGNATUR MP E JP E. CORPORATION-# 3281C PARTNERSHIP0#1 lLLC0# COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE __ _ ._ STATE MA ZIP 02664 TEL 508 394 7778 CITY SOUTH YARMOUTH FAX 50839- 4- 8256 . CELL NIA 1 EMAIL�accountspa aable@efwinslow:com _ __ The Commonwealth of Massachusetts ch usetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 �• "'�yF www mass gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMUTING AUTHORITY. A lieant Information Please Print Le ib1 Business/Organization Name: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: Business Type(required): 1.0 I am a employer with le_employees(full and/ 5• 0 Retail or part-time).* 2.0 I am a sole proprietor or partnership and have no 6. ❑Restaurant/Bar/Eating Establishment 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 3.0 [No workers'comp.insurance required] 8. ❑Non-profit We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have no employees.[No workers'comp.insurance required]** 10.0Manufacturing 4.[1] We are a non-profit organization,staffed by volunteers, 11 ®Health Care with no employees.[No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. , **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address:23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL, MA 02467 Policy#or Self-ins.Lie.#1821A Expiration te: Attach a copy of the workers'compensation policy declaration page(showing the policy number01/2 andexpiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceCM rti , the a��is and enalties o perjury that the information provided above is true and correct. r�/ Si nature: \— _ r -� J / Date: r'a_ 13 I l .tom Phone#:508-394-7778 Official use only. Do not write in this area,to be completed by city or town official • City or Town: Issuing Authority(circle one): Permit/License# - 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia `� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . CITY T W d I • I MA DATE-3)77r. 1 PERMIT#,i'6 orC ' JOBSITE ADDRESS,. U /y//}//USiPf-f'-T WNER'S NAME I- j�4-.G,ifP1 '_J ___-1 G OWNER ADDRESS 2 m� '/ ' FAY - __ TEL 5--a' 77 lvly�l I._r,t_, s TYPE OR OCCUPANCY TYPE COMMERCIALD EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW:F_-1 RENOVATION:El REPLACEMENT:VS PLANS SUBMITTED: YESO NOD APPLIANCES 1 FLOORS.-} I BSM 1 I 2 3 4 5 6 7 _e s _ BOILER I�T^I. -I . 'i_ I. i __ _ 21,_- _____ BOOSTER l 'Irv. i I__ l ..~I- „!r.r-,-r'IL -_ �I 'L CONVERSION BURNER I _-. I R-11_ _Vi.- 71^-. ��- _ _ COOK STOVE fI DIRECT VENT HEATER I . _ DRYER E I.. .EPCE r-J FRYOLATOR 1--- 1 r- `^1.•-- :I 'I._ • FT. �®11,1T-- --�...,.'® FURNACE I _;L. - -,I 1-_...- 1-_T.;.( _-.-__ •:._- :I --®® - i 'I. GENERATOR I_.:_. GRILLE I.-..v -i... ;(..-... _•I'._ .,_....-.-,.I. ..I ® �. INFRARED HEATER I 1 ':I. -`rr_-____:r::: --. `L,. ® L_----<L-"`-.. LABORATORY COCKS .'1�-- j. __ 1—---:1 --1r _ mp�i. _..'i. . MAKEUP AIR UNIT .'L ,-- OVEN c_. POOL HEATER r� . I--i .•,_-- il_`_-1.L_ •[MEM I--••• ROOMISPACEHEATER IT:- -: ATE•- i�J= ;I._--_•:1_ ._`_._. C •L.. _ i ROOF TOP UNIT I. :(.. ..-.` .'l. `mil �. ® l-�. (...,...i TEST 1 ��uE�� -l�='1 UNIT HEATER • Jr-. �iC _ 1_-1-. . . UNVEN T ED ROOM HEATER I. _�i r ,� (��;L v,,:�I,� I .-..1,-`• •:--• WATER HEATER . _________ _ — OTHER I __-_____= � I-= _ _..._ --_ ;�h i Yi; j r... -I.,,.IL":: L..__1 INSURANCE COVERAGE c) I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ID c}3 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW V' LIABILITY INSURANCE POLICY 171 OTHER TYPE INDEMNITY[J BOND L. 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. .kA CHECK ONE ONLY: OWNER 0 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 t 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 com nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ 1 ''4"i PLUMBER GASFITTER NAME I _ STEPHEN A.WINSLOW W ��1 LICENSE# 1229 —r SIGNATURE I MP I L MGFD JP E l JGF _�LPGI CORPORATION i# 3281C ARTNERSHIPD#,.�. ' LLCD#I-T„'r._ :I COMPANY NAME:I_EF WINSLOW PLUMBING&HEATING ]ADDRESS I8 REARDON CIRCLE :1 CITY SOUTHYARMOUTH , ._ STATE MA�ZIP 02664 TEL 5083947778 ,, .�...__iI FAX 508-394-8256 I CELL NIA �_ EMAIL accountspayable@efwinslow.com • . GCS 4e 46 5 s 1 . 1 . Q The Commonwealth ofMassachu3etts .,.,>�i 'iDepartment of Industrial Accidents g� X Congress Street S trAft utte X00 ` ` Boston,litA 02114 2017 o. www.raass.gov/dia Workers'Compensation Insurance Affidavit:General Eusinesses. TO BE MED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Le ibI . Business/Organization Name: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: � - Business Type(required): 1.2 I am a employer with _employees(full and/ 5. 0 Retail or part-time).* 2.El I am a sole proprietor or partnership and have no 6. ❑RestaurantBarBafingEstablishment 7• ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 3,0 [No workers'comp.insurance required] 8. El Non-profit We are a corporation and its officers have exercised 9. 0 Entertainment ` their right of exemption per c.I52,§1(4),and we have 4.❑ no employees.[No workers'comp.insurance required]** 10.0 Manufacturing We are a non-profit organization,staffed by volunteers, li•®Health Care with no employees.[No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providingworkers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address:23 COMMONWEALTH AVE • City/State/Zip: CHESTNUT HILL,MA 02467 Policy#or Self ins.Lic.it 1821 A Attach a copy of the workers'compensation policy declaration page(showing the policyExpiration �numberate:010and expiration date). Failure to secure coverage as required under Section 25A of MUc.152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I I do hereby certi the aifzs and enalties o perXury that the Information provided above is true and correct. Si nature: r --<. . f Date: j ! f4- ' . Phone#:508-394-7778 • Official use only. Do not write in this area,to be completed by city or town official City or Town: AuthorityPermit/License# (circle one): . Issuing 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia