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HomeMy WebLinkAboutBLDP&G-23-9016 . , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK :�;:ilk-� CITY , . i MA DATE14 _ /L , PERMIT#I 1)P-Z 3" 7d/b= JOBSITE ADDRESS / Z o 4f j L,`ly Rd d 5-7q, OWNER'S NAMEIP419yi�Je/a7-- tZ u A t? POWNER ADDRESS .2-4 /Vtrc?N /7i 1''- % Sr. 2_ 'EL,la 3 7f a .2,f-',t;FAX ] TYPE OR OCCUPANCY TYPE COMMERCIAL E. EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW:D RENOVATION:LI REPLACEMENT: PLANS SUBMITTED: YES L NOD FIXTURES 7 FLOOR--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _. MIliI .--.':�-_ !:L,. ._;I,.: ._d_.._ _i[Tr- _.. s. DROSS CONNECTION DEVICE ram_® I L— 1.- _ I� DEDICATED SPECIAL WASTE SYSTEM ® �-.-•__ aid-_._ __., 'EWE DEDICATED GAS/OIL/SAND SYSTEM IMM1 F- I... . ' mor� ®milm DEDICATED GREASE SYSTEM MIIISMIIIIIIIE— ( 11111®111111® ___ DEDICATED"GRAY WATER SYSTEM Mili .. .r __ � � owr DEDICATED WATER RECYCLE SYSTEM 11_,L_....'r._.. _ ; [ �(- j m � w _ DISHWASHER I: •I. I :ter— i sr_ ... � Fr, f`—?f"_T I L DRINKING FOUNTAIN r I"11 7 -"j r--� �� 1._. F .: � r-r"--- r--'Lz__- `\ FOOD DISPOSER I.. r- ;ram r I �I._ I� .. ` I 1. " �J[ ' FLOOR/AREA DRAIN .�.-�.�L_._�_ . ( ._..._.(_:._,_i---„ ,y-..�_:. __ , -Ti! I, r__ • r-.._-r-_ INTERCEPTOR(INTERIOR) r�lr —. MI . __1 .—v h- n'l KITCHEN SINK Ii . 11_— 1— r— I__--- - ` LAVATORY I_ _'�I__ — I-- I _ imam I i.- __ ; i-- ��� ROOF DRAIN I r I �_'SHOWER STALL ^_Y__.1 _. 1 I I_-2_i r__, _-� . T -_ FM SERVICE 1 MOP SINK I -I _ rY:- 11-11= - _',_____.1 •_ TOILET Mg T ,I IL _ �i I— .�( _i 'j II G ,__.__ URINAL r: I. I-7 _ I .. I- r- 'I WASHING MACHINE CONNECTION Ii 'T I - I _'II -1I i (-TTL _ I. II. l f WATER HEATER ALL TYPES MillEML _ I ' I - !I r m � WATER PIPING - - I . r� r- MI I I I fir--_a OTHER _ ._.. T_,—_____Mil - �_ .�1T '�I::__.-_ r`�I ._ '�I . -1®fir- MIMMEr fi ��� ®�� _ ���r a l a�.�wr-. --IIIIIIIIIIIMMIII -Mt {- -AM-MUM ._ �l r E w C.-_ -,.-'_: -� .�_- i.:..:_• 7: . _71 L _:_ 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 1 OTHER TYPE OF INDEMNITY 1-1 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. CHECK ONE ONLY: OWNER El AGENT 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 comp nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. n LUMBER'S NAME STEPHEN A.WINSLOW _ _ , LICENSE#_12298 I "-- " U XirY P SIGNATURE - MP[3 JP El CORPORATION 3281C ;PARTNERSHIP#L LLCE]#1 COMPANY NAME[EF WINSLOW PLUMBING&HEATING ___I ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA ZIP �02664 TEL 508 394 7778 '_-----1�_ EMAIL accountspayable efwinslow.com .) FAX 1508-394-8256 CELL NIA� � � - p o2 wn-- ll epartonent of Industrial Accidents I'— ]a f Office of Investigations 3-ellll= _ 600 Washington Street 'iiir=G� Boston,MA 02111 ..` a �Yu�, www.mass.gov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please(l Print Legibly Name(Business/Organization/Individual):l�•C /�'F•Wtr\$IOW YtV,...iainc( L0t03-, , `m,file. Address: ' Q ot� i C2rtat?.— (J a City/State/Zip: Soo kh 'Cfv-.Cs.,Wt MPc Phone#: Oa-394-17?C1 Are you an employer?Check the appropriate box: Type of project(required): X,, I am a employer with '70 4.❑I am a general contractor and I 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors t.❑I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5.❑We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their t.❑I tuna 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.] kny applicant that checks bex Nt must also till 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 subcontractors and their workers'comp.policy information. km an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site rormdtion. n —_ isurance Company Name: (�tC Yp CAJ keii S stwrA/t(.2 \ auwit-VT-j olicy#or Self-ins.Lic.#: I‘iS a I A • � w 11'' Expiration Date: (-( al"�n A,Site Address:a3 n vvicv) -ee-Prh Al Ov2.3 rn7( City/State/Zip: O,.)4(67 .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 :::•.st the violator.Be advised t.:t a copy of this statement maybe forwarded to the Office of ivestigations. the DIA for insurer :.verage veri Al;on. t do hereby cert(un, i penal`es jury that the information provided above is true and correct. isoa Date: (c`. i AOk5' hone#: SiVl•?54.777X 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#: 5)\'‘r — --: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,._'tI .. CITY �S a_cr'/.I?` . __k_14 _ , 2gT riz./.. // i:: MA DATEa,;.,.. 1;--.Lka.) PERMIT# ! '.7 23"V/& /b ` h rCST_--__.r._ JOBSITE ADDRESS[/_7 ?4117 ___ Z_ #, ___ 7_ OWNER'S NAME -r. 7,-„/ 'c► L n L- -�/ 1 GOWNER ADDRESS / / ni ..,,: i ',1. TElt-- ; ��' 6 1FAX 1 TYPE OR OCCUPANCY TYPE COMMERCiAL[J EDUCATIONAL 1� RESIDENTIAL PRINT CLEARLY NEW:Ell RENOVATION: F.il REPLACEMENT: E PLANS SUBMITTED: YES F, NOLLj APPLIANCES -1 FLOORS--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ I. _I I, _ . I. .._. 'i .. . i _._ . _._II_. . . i. . . _ -�i . II_ .. .._i!_ . .�' .. , 1 ;1. _. . .. _ _► . BOOSTER L I_. _ -Tr._ _ l. . _ I_ L . wo ...,l .- I_ I iT.. . 1_ I I. . . f l _i l I(� i_ !, CONVERSION BURNER ( _ __j. __ E. -71l— .1. _ i' _ _w ._w —t — . i __. .. Iy3 .. µ-il :Ti r ;__ • COOK STOVE 1_.. I _._ —_ — 17 + I ,i �" 1--•--1 I.-_z.. x 1 . . . La . . 1 i 1 .1 M...� .E I7 .-- . . DIRECT VENT HEATER I_ . 11 ---_..II_W i1. :ft . _il_� �II.... _,q . jI .... 'I1 . . 'I - .�II. —yil.r..-f1r+.__ i_ \ DRYER j_ Iw...._...4... _ 11 .. I I .A._. .[I ;j - . IT 1—. ( . I I.. I--- i .� I� I.._� I_._-.:._ _.._ Lam I_ ;;I =i; ;1- ;1 I j�. :�_ !. 1• I i FIREPLACE _ . `: _. _._ _ ._ ._ _ _ I_ - ! I_..�_ i I.,,.. .'��,....�i t ._..._ ---. k Imo_,._. I�r .._. lw- .�_.�� —� '.-. FRYOLATOR . . . —1i ....1.1..._ _ .. I :I,.. , . I. .... I �. :,1,. FURNACE _ _ _ ` I . ' 1_ . . . ' I . ._ s • _ . `1- -- . . i. . I .__. .+I J __.I I._. _ .. - GENERATOR .. !. �_ f. !�.....1j�.:r. � �.�. .�.__ �_;..----.��,_�.._.,�_-- ,--,I —�---,�- i 1 .. �i._� .: . `_. GRILLE 1.---_ --- -71 --, i`_... 1------ -d-- 1 _. I,--_ 'I.� .._. I I : I , 1 - '� i _ �- INFRARED HEATER 1_ . .. 1.-. .�, E ` i. . _._-',1.. . . _ 1.. . i . . . `I. I .. i : .� ' : +� . 1- : -'1 _.. ._1..... `J " — ' .LABORATORY COCKS --'. L__--1 I___ ._. I—. .---1'. . 1;, _:_ i,. _ .._.. I__ ,1- . _ i . _ h_ . 1-- -' i- .i I4. ; MAKEUP AIR UNIT I_ ! ._ _. I --- ' . -. _� �- - . ._ 1.-_.- . I ` - _ L` I- OVEN 1---11 „ ,11_ , . . ..I. T- -_ I7 L. .---s l - . i 1 _ -_A i— I -_`I. H. _ .iar '!.i —11,—,—... POOL HEATER I 'i . . ,IT I I rl_._. _i .`I _ ll _�,i fl_ _ 0 --ii, `I 11. 7. 1 ROOM 1 SPACE HEATER __ —►.f I.I_ ...__ I__ _ i i_. _ . .,i L—.._`I___ I I II .. , ROOF TOP UNIT �___—i i` .1 I• [ I. ;1 . 1-^- 1 . _ I, . _ H 1 . —_.�_: _II. i . TEST ,n,r: I-. I . :I_. .- `I� - 4. ,._.1'.... ... d1 'I_-. - 'i __1.,.. i_..., ''1�-.,�i(_.__- I- _. I. UNIT HEATER f L�. ; 1.. . . I1 i.I.. _.. . __1_. v _.. . . UNVENTED ROOM HEATER i 71. .--11 .. ._� I-_`"- �,rI.7d. . . J _. I._ . .. d .._ 'I_-r [ i l- . .�i: i 1. _ . _ 1`'--=. WATER HEATER i _ -�_' . . ' • _ .. ..1 T. OTHER I ._.__11.—.. . ' 1_ C ram ' i;.._ i ..------.--11 .._.. ' .. �� I� � j 1 ° 1_____________ ..._________,______) 1-_.._ ._ _ i -.. ' I__ . . ----- T.---- - - . I-T . _ y`¢Pb.t fl111+vx�_'..•.c 6lS'IYWrtl3CSW ''....a Cl flMt flJr A l: 1� .. _ _____.. �. ti..� ♦ - w ii r f` 1 � I aos �,_1I % - — INSURANCE COVERAGE have a current liability insurance policy .or its substantial equivalent which meets the requirements of MGL. Ch142 YES P i NO Ei I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LI OTHER TYPE iNDEiVNITY Li 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. CHECK ONE ONLY: OWNER E,` AGENT L.,.o' 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 complianc 'with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A. WINSL OW I LICENSE # 12298 SIGNA RE MP r l MGF D JP . JGF D LPGI j CORPORATION F # 13281C y� PARTNERSHIP El#=1 LLC D# _7 ,_ PLUMBING & HEATING ADDRESS 8 EARDON CIRCLE _ COMPANY NAME.�EF WINSLOW L� R r -- • CITY SOUTH YARMOUTH STATE MA I ZIP 02664 TEL 508-394 7778r.. _� Y FAX 508-394-8256 ; CELL N/A _ ��,��I;EMAILI accountsoayable@efwinslow.com ' :p.m:_ Department of industrial ulcciaenls _1 ,� i=511 Office of Investigations i!;;,y 600 Washington Street .��= G Boston,M4 02111 • ,� • '� www.mass.gov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information C ` ' t Please Print Legibly Name(Business/Organization/Individual):l—•c.IN 1,n5 i O.J Q[ ,,61 L q t0.1'�✓�Q- c' kit✓t, Address: g (Zetrdtan C�ra.]R— (J d City/State/Zip: So.s u 'v,c,..0 I'4Pr Phone#: 50S-399-1'1?V • Are you an employer?Check the appropriate box: Type of project(required): I am a employer with '70 4.❑I am a general contractor and I 6. ❑New construction .employees(full and/or part-time).* have hired the sub-contractors ',.0 I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑We area corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions i.❑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 employees.[No workers' 13.0 Other comp.insurance required.] kny 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 formation. tsurance Company Name: 4O t o k i o-h j_rtgcwt&si C.o \ gn l✓i,-) olicy#or Self-ins.Lic.#: I' .I A. - Expiration Date: t—[- anl1 )1)Site Address:,3 Mov1 v'-P0-1 1-h A-d-ed, CCdlyk}l* 0,11 City/State/Zip: b„1 W 67 teach 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 t at a copy of this statement may be forwarded to the Office of • tvestigations the DIA for insuranet:coverage van on. t do hereby certify u e ains an //penalties o pe jury that the information provided above is true and correct. ignatti3- ��„lies Date: I DI 31 1 a©1 ' hone#: .ciy.35`i.7 77g 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#: