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Home My WebLink AboutBLDP&G-17-003152 OP6 c- �1, ... mASSACLILzE 7`T S UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r-= Fe,=_ CITY � sz5Lr MA DATEi—L —/ G PERMIT# 11)—/1`6617/s/Z ' "'' OWNER'S NAME C cif JOBSITE ADDRESS � ,��sea��L'��s/� LA/ ,,�1.��',,...�,--_ �L 9 AX _ OWNER ADDRESS 1 TEL} ?.`/ v y y„T , ..... , TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT PLANS SUBMITTED: YES�] N0 CLEARLY NEW:(j RENOVATION:LiREPLACEMENT: ] FIXTURES 1 FLOOR—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB L- -1._,.. I II -r- I 1-- iI ,I a _1- 1,1 `�.,__.: I CROSS CONNECTION DEVICE s { I { DEDICATED SPECIAL WASTE SYSTEM ( r _I ii.,; if 'I 1• 'I I , "''{ -= . � ._a. ____ DEDICATED GAS/01LISAND SYSTEM r ,, ! ` 'I � r . I J l _- I ,,- DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM �_ I I I—� i _. F__ DEDICATED WATER RECYCLE SYSTEM I. i 1 J i __1 _ ' DISHWASHER L_. I 1 ; DRINKING FOUNTAIN 1— ! I '1-- 1 1 I" �I_ L _ I __ — — I FOOD DISPOSER 1-------:L.._ _ 1 I IF I . I - FLOOR 1 AREA DRAIN . , I I I 1 1 I- I_ I 1 V _ INTERCEPTOR(INTERIOR) I i .: -.i y- I— l J I _. F ,I I ,.. it __ r L KITCHEN SINK P i. i iY [ I ! I_ C -_ I- — LAVATORY L, --- . _ I , '•' ROOF DRAIN SHOWER STALL 1----I I---I -`! i . h I,___._1 5 -I_ 1-- I 1 N SERVICE 1 MOP SINK L: _ TOILET I I I ,I rJ I I 1! M URINAL --- L r-- 1- L -I II—�r- I- WASHING MACHINE CONNECTION I� I I P r— I WATER HEATER ALL TYPES i .-. �.___ .. I ._ I_ _.._ l I n l_ I WATER PIPING I r — I I I ( I r I, OTHER t I I i r f' -'�.""'CY'.. " _: E l- I 1 I. I d _.• 1 .. I. I i I I _ _ l' 1 t I "` INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO LI IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY jj OTHER TYPE OF INDEMNITY 0 BOND Li 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 I1 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tr e 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 iance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L--- PLUMBER'S NAME wSTEPHEN A WINSLOW w LICENSE#[12298 -I SIGN TURF MPH JP'4: CORPORATION0# 3281C PARTNERSHIPU#L _]LLCD#, ,_ _m COMPANY NAME E F WINSLOW PLUMBING&HEATING j ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH J STATE MA ZIP 02664 ` TEL 508 394 7778 FAX[508 394 8256E_1 CELL N/A 1 EMAIL accounts pa able@efwinslow.com .,,,,,.J 1 De'po.'f'ment of rgOstPir i dei r;illi, s i per ' 500 Wcshang€ola Sui're? 1. r Boston,MA 02111 • Www ra ssgovld Worker ° Compel,sation i1ffis311rt inch davit: l uildereo/Contreactors/ iectrriciansiflnnaberrs A. licant Information Please Print Le II Dame(Business/Organization/Individual): ,c.vv,,r51ow Ql0,,,,a(01, a. IA�.o�,It Q,. fit if } Address: �e�'i� C'errs City/State/Zip: Bosh Vru--,cr, , C-Or Phone#: `5OS-YIN-17etC1 kre 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 employees(full and/or part-time).* have hired the sub-contractors 6. ®New construction ❑ 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. El Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their L❑ 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.❑Roof repairs . . insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] 1.ny applicant that checks bok#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. ;oontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. Jim an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1 formation. { tsurance Company Name: ( \Y ..,.3 cA0 jo-f S(NIA A CP_ C(ANN N:IV-1 olicy#or Self-ins.Lic.#: 'Y.s I A Expiration Date: c.—i — a'on )b Site Address:, 3 G IWS Yn vi 0-4 -e CNn`1}r`i y I'M City/State/Zip: O,)Li t,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 against the violator. Be advised t at a copy of this statement may be forwarded to the Office of • tvestigations�he DIA for insurar�e overage veri anon. i do hereby certify cane a ains an penalties o pe jury that the information provided above is true and correct. i atuY • L. r_ti Date: i DI 3( 1 a o k 5' hone#: .c() • ,cN> 7 77X Official use only. Do not write in this area,to be completed by clay.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#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ..-.-0.,......_-_. 7CILIM'-2-'r; CITY 441.--Sf 4/0"-- I MA DATE / Z-,4 // I PERMIT#/ :X/9/9"."17---04) g/ 04.• JOBSITE ADDRESS. it_244044 Lr s.,- Z/j/ I OWNER'S NAME G OWNER ADDRESS TEL . , ,7- 51 y..79''FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL_I EDUCATIONAL „j RESIDENTIAL PRINT CLEARLY NEW: j RENOVATION: ....i. REPLACEMENT: 4 PLANS SUBMITTED: YES...,J NO APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER __...I.....T__1. : i 1i ( I 1...._.....1 1......___I 1,„.. I . . , BOOSTER ..,__i___J. i .__,..1 1......__C I I..._.1._____I__I___I J A_ CONVERSION BURNER ___, _._I— ____.! _____i.____1,....____j . __i __ . _ 1 _..........i .....__I COOK STOVE ' _,.I DIRECT VENT HEATER , _...i• ' ,,,j i'... i 1 , DRYER . __ .„., , : „_ I 1 I.. _..„.1 - _. FIREPLACE i _...1 ....._,,i. f_i_ FRYOLATOR ____:. __...._i , i j , I _ I _ ._ .„,„_,,i FURNACE . ",„,„„,,,,J i_..........i, GENERATOR GRILLE i . i.. '„,_____I,.. J ___..i. I , '_ . . _ _ _ INFRARED HEATER LABORATORY COCKS , MAKEUP AIR UNIT t_...._ .. OVEN -._.,..`/ ----j,.--.1 ._15:. .. ......i__.„1„... _1 _ POOL HEATER I .___I , ..; 't- f-N: ROOM!SPACE HEATER .,_ ! __I ..1 _2 i\r) ROOF TOP UNIT T 1 - t. __,I -......_ TEST ... '- • ___,_ . _ .,.---,, ....) UNIT HEATER ...,_..1 ' , i i UNVENTED ROOM HEATER i ; ,__..„, _ I i___1 _ f 1 WATER HEATER 1-/ ' i ,......____ , -,----- - , --I OTHER I __I .i__I _1 , i ;I . _._I I-____i J I I _........_.; i,.._i I. I ....._ , _ j ..., ', i ...1 _ I 1 , j , i INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 l< NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i I OTHER TYPE INDEMNITY ___.1. BOND I , 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 A 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 nd 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 compli ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. lialAi.‘,__Jeizi. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE# 12298 SIGNATURE --- MP ...!...'.I. MGF _,...i JP ....I JGF_, LPGI CORPORATION „:!,j# 3281C ' PARTNERSHIP __!:# J LLC # COMPANY NAME E F WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE I . I ' I . . CITY SOUTH YARMOUTH I STATE MA !ZIP 02664 TEL:508 394 7778 1 [ I FAX 508 394 8256 : CELL N/A !EMAIL accounts a able efwinslow.com - 07- _w_:= Department of Industrial Atcclaenrs A= r . l— Office of Investigations —l:t�i_ 600 Washington Street f. Boston,MA 02111 • •,..:..'' www.massgov/dia ' Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly • Name(Business/Organization/Individual): E,e.NN i AS I 0 vv `�1V,n410 anc� 4 t-)to._1-% cam, I fit, Address: cZc (teams, C2i1Q- City/State/Zip: Soo Sch (orwtcs.x1'tn t4Pc Phone#: SO - 3cN-177S1 Are you an employer?Check the appropriate box: Type of project(required): XIam a employer with '70 4. 0 I am a general contractor and I 6. 0 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$ 7. 0 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. 0 We are a corporation and its required.] officers have exercised their 10.0 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 12.0 Roof repairs . . insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] 1ny 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. :contractors 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: CA�l l'11C .i,n,r(..Kk el c_e_ C l✓ri olicy#or Self-ins.Lie.#: ` $'I A Expiration Date: k—1 - of t"-) )b Site Address:a3 Ginnr'C7r1w-ea•-(4h ,r `a1 0\23 1 r I. M1 City/State/Zip: 0„1L167 .ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). . ailure 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 • westigations __the DTA for insuranet coverage veri aon. t J do hereby certify un'e ) safl1Pe:. ieSOPefU1Y ain that the information provided above is true and correct. ignatuTe;—.__ r Date: 1.. .) 3 l l a01�' hone#: ..c1,) •: `1`1. 7 77X v 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#: