Loading...
HomeMy WebLinkAboutBLDP&G-17-001372 ,. MASSACHUSE T TS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i --ct7$7/, �' � , CITY ?��ti,� ��rz l ��,{ MA DATE - 7- -2- /6'PERMIT#/ �/7 JOBSITE ADDRESS /O.g/lES% ►�c V��/ r OWNER'S NAME -Tf_&k f c C6 //S K _/1 ilj OWNER ADDRESS LuM.22 jo w/I`,y �02 TEL 5479q 7(5''3/jFAX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL 0 RESIDENTIAL 31 PRINT • CLEARLY NEW:D RENOVATION:17 REPLACEMENT:K4 PLANS SUBMITTED: YES[ N00 FIXTURES 1 FLOOR--► esM •1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 I I(_-a L---F.-.7 L--t..I_,.....i L,...,_�I ',.=sue_ _�. -5 -. 1---- .i E ` a CROSS CONNECTION DEVICE I .--,1_..,__ 'I�TI,,,_.,,_y1,_.,_ (....._.IL,-_ 17.1: ,:.1_._.1.:((- E.-. I.... _: .-'(. 77 DEDICATED SPECIAL WASTE SYSTEM L_____ L..,..I I,.. ... L. L.-_.- i E 7I__.__v- I______-_-11L.._I__.. . L.-_,!:I- [.-�!�>--_I DEDICATED GAS(OIUSAND SYSTEM I__LT_ _:( ;__ r L.. . ? . iT L C--__ -'=1-..- :1_--` ^.r DEDICATED GREASE SYSTEM [.T_1- ~ �:I. _ ;I . -7I,T_ .II_. .1,__.,._1.___-rP,Lll:_..-._!I___.- I, .. ._f .-rlL DEDICATEE/GRAY WATER SYSTEM LE... :r ]ll !• _;_..,__a l� _#I:::.,:-,�i lr't I :C .l- -7--1� -1 E- DEDICATED WATER RECYCLE SYSTEM ,I ___._:I.. 1._.,,.-;L,=T.-11 [_ [ L --31. 11 i�� ' DISHWASHER -,1__.__,I -.. ^G=13 ;1�-°... 1.... _C ... ..I '�..5�-_--_L_.=._::. DRINKING FOUNTAIN r__ -FT.- 1..,.._ r ih - .1�-r--��- 'I-_.-1—�'r-- _`_ FOOD DISPOSER .• L,_._t�T_- JL,......_:r:- :E—l._...... 1, :...,�;L_.._�,�._>I.:. �_`1 . it l7'17. M FLOOR IAREA DRAIN -�I_-=-_1_-= 1_- _�.- 1 ..�L <. _- l __'h,. .'il� 1. — INTERCEPTOR(INTERIOR) L-:_.`II�t-1T—.h.-.^���'�-. -• • •• -- �- E � �`�`- nrl -KITCHEN SINK I_^_:I f 1 _'I-__ 7711._.._..„II ._f l. ITT--E ; .'I T- .1 . LAVATORY FIT `mil___.. 'I I. , .:1L [..-I- I--1 .. _ ;�. ROOF DRAIN 1 ?I '� ;�--'�-- 711 .71L---'I -- `�-Ir � ':r .._ ; SHOWER STALL ..1 -.=11,..., :.:Et- L--__il.-:..._a11 . :i1--1 71,__.._ -1L- ?[17-( SERVICE I MOP SINK 1_. I�- „17.71:� 1._ i L{:-.-'=17. .') .-.,'L '� L '�- TOILET • 1 1 it .. '1 !�.. . vil { Jr:7i _� `' !_ ir- - URINAL 1_11-. :'L....,_.iLITL _._:1-...._IL_,L _;.I..,.:..;. ..: _ . .1 . .. - WASHINGMACHINECONNECTION _I.-.._.....il 71 _IL-.--(•n•-:1I,_ 1.L..:... ...II- . 'II-i'� '1. ,.f1.—' --3 -1 _J WATER HEATER ALL TYPES il_ __,1_-.' _:I ':E ( .....ir_ ..__iL I.._- _ '�7 .+L_` CI-, WATER PIPING =11 ;�E�If .I___ I. - '�� = I _ OTHER - - --�:1 ... � '.I-__;� ,1;-. ,��,I ._ ��.. . '.1.. . '; . ..-.if. -1-.'C_-_- �.. �-=I 1- -T.. I --_11 ._ n.-31---.i I. ;1 :.I :fir•_ 1717 __-_�...._.._'-'--_._..��__�.— -_L ::C a:�.; _:C— ; ail.--. ..a _"'L_,aL..__-�I ,�,-_. I— -_ -3I— �� - __� _._..... _._� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO LJ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY El BOND D-• • 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 0 _ SIGNATURE OF OWNER OR AGENT and accurate to the best of my I hereby all plu that mbingil of the details and information I work and Installationsperformed have submitted or entered regarding under the permit Issued for this applicationis pwill be in corntion are a nce with all Pertinent provisi6n of the P Massachusetts State Plumbing Code and Chapter 142 of the General Laws. a4:(..1 PLUMBER'S NAME STEPHEN A.WINSLOW ____J LICENSE#I '121.9_P___21 SIGNATURE MPO JP© CORPORATION# 3281C _ I PARTNERSHIP F:# 1LLC0#= OMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE — _ __�, -1 C - CITY SOUTH YARMOUTH _ i STATE EFL] ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL NIA r EMAIL accounts ayable@efwinslow.com T_ - - /" t Depfr8Ment Of llnditstritliAcCMPEs i l Office of Investigations t. Md 600 Washington Street Boston,M4 02111 Nkrwww.mass.gov/dia ' Workers' Compensation Insurance Affidavit: is nildeirs/Conntractors/Eleetrieis;r,s/Pkai miters Applicant Information biy Please Print Legi • Name(Business/Organization/Individual): E.' •Vv I AS 14w Qt v��o wtc) 10.��Yncl. ce_ I✓iC 6 J Address: ' (4o-ar it Q. • City/State/Zip: Soo kt^+ 'cr v—,0, MP Phone#: S-3 t-1 T1 • Are you an employer?Check the appropriate box: Type of project(required): , I am a employer with •7O 4. ❑ I am a general contractor and I -v`` 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors ;.CI I am a sole proprietor or partner- listed on the attached sheet.t El 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 required.] officers have exercised their 10.❑Electrical repairs or additions i.❑ I amda 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' 13.0 Other comp.insurance required.] thy applicant that checks boic#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. lm an employer that is providing workers'compensation insurance for any employees. Below is the policy and job site f formation. isurance Company Name: irty J C \-)ri.liclA TIS(NCR.(I Copv.A-VILLA olicy#or Self-ins.Lic.h�#: \ B.a I AExpiration Date: �-I " aot--) )b Site Address:D3 CO Mehlvi-ee-1rh At-e, CG 3kyrt} * If1\ City/State/Zip: C),-)L4 to .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 the DIA for insurar�etoverage veri eaglon. do hereby certify un e e ains ana penalties ofipe jwy that the information provided above is true and correct. t, �' ignature; / ,sue Date: (on_� 3 i 1 a0‘�`� hone#: ,c)g•3`i"I. 7 7 7 X 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#: IF 0r--' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,11 a l c� CITY i, .f1-4'..'.-� ---.s MA DATE. . 2:-?--I PERMIT# P '7�C�j37. JOBSITEADDRESS1, E -% 6-- LV',/ia/-' 1 OWNER'S NAME -7a• ., e c/S' .--- 3 OWNER ADDRESS f/r jTE4,';di�7yX,7i3/ ;FAXI.: :. --.'i TYPEIFR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL D RESIDENTIAL Egt PRINT CLEARLY NEW:El RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES} NO� APPLIANCES 7. FLOORS--, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER l f 11_ . _. I. I:.~ i al:. .._+I. it= "L.... i BOOSTER ���I I�.._ ., ft L_ i� (I I, CONVERSION BURNER i<_.t1 _ .r(-_ _ j_-.-__i1-.• .--1-,--- II -11----'I II i .11- AI ��i17 COOKSTOVE .!. ....'f 'l n-. .li . if it (i i1 it II ..:-..a DIRECT VENT HEATER 1_•_._iI_.__...�L__- .,li. . .cl_.. ._ l- C--- ,!I 1I ._ `I__-_ 1 (1 it 112-1I . I- 1 1 ti DRYER 1_ !. M If_� '(� (. f _ it ll - I. r. \41 FIREPLACE 1- Jli _1! 7..I EI 'I 1•_-)1�-'I- - -.'i_..__ 1' 11 . ..1177.1 In FRYOLATOR i_... II. _,I .i7.-Tr"... `t. , I. _ ;I L. .i_ 1 ._. I !f. f�11--_L' I. 1 11 11 `lf.--I. 'i II .l. t i�-'- FURNACE ! _ I `il� 41 -- -4,------ GENERATOR 1-�_v '1T ~1-- ,I_ -Ili--- •i _._.- ii. -II. 1I— '' 'I_ .11... f1.. _ GRILLE 1 ! H 1 -I I ,,1- .._ I --:,1-.7_I' ,i s i--.._.11 .. 1 INFRARED HEATER 1 ~. °i_. 1__._ 'I___-'s1- _;!- tii ;1._ ..__il — I. i ^ ih.- .LABORATORY COCKS I :.,I.. . .'1 , i�i. ,-li -`I '1.- I ii I1. ?1..-- !. MAKEUP AIR UNIT I--i' --- I _ I i.I� d . iI- -il ,r '__`1,__.. 1 tf . l i I i 1�� OVEN 1.-T_ f1 fl `1. fl kl ..i•--• ..I _ -- � � �{ POOL HEATER L_'I 'I I i I - - ROOM I SPACE HEATER (-.,_i L- I �_ f I i .1 i ' --;I -1 11 lLT ROOF TOP UNIT (�_-1E— 1(- II. aI. .. pl. il.. . .il _ - • TEST �-- i 1 _ 1 i 1 I J. UNIT HEATER I -.:11.-: 1 i ii 7 UNVENTED ROOM HEATER f— is .. 1.. .="L.. -.,1.( — ll ti 'I ;i -r f ,.6r- i1 }Ll<_ WATER HEATER I fI II ... ir ! .-.1 1 . ;I —;1^I1 r1_, 1 >i. ;1 OTHER .... I ....'I ( 177.7.1 _ _ 7 ) __ 1 1, .1.....- 'I jl: I .. tc i tl --L---�� `� T INSURANCE COVERAGE I have a current liability insurance policy•or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY D 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 0 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 west of my knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in compllanc ith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��v2 >6L4t,e-g«sr J PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE#�12298 SIGNATURE !1 PARTNERSHIP# ,LLC #I:= MP �i MGFD JP�� JGF� LPGI� CORPORATION�# 3281 C_�� COMPANY NAME:1EFWINSLOW PLUMBING&HEATING i ADDRESS 8 REARDON CIRCLE " _ STATE I MA ZIP 02664- 1TEL 508 394 7778 CITY SOUTH YARMOUTH _ L Y FAX 508-394-8256 uii CELL NIA 1;EMAILI accounts a ap y ble@efwinslow,com _ _ _ Depdarbnent oJ-hhamstr at Acmews _it—• Office of favestigations , =;:►1` 600 t.shington Street ti„ Boston,MA.02111 Ntap. " www.Pnass.gov/dia • Workers' Compensation Insurance Affidavit: ]Builders/Conn>trnctores/E1ectricanns/p1aambers A licant Information Tease Print Le BAY . Name(Business/Organization/Individual): i •vv AS I Qw Q(V,,.,\.[0 kelcj ,2 k- ���c q ��_t I iC 0 � l Address: Q t V City/State/Zip: So,s sci,\ ('-1Pc Phone#: 5S- 3c14-1'1?S Are you an employer?Check the appropriate box: Type of project(required): am a employer with `7O 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El 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. ❑Building addition [No workers'comp.insurance 5. ❑ 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 11.0 Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.E Roof repairs insurance required.]t employees.[No workers' 13.❑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. lm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site rormrltion. isurance Company Name: l h•,,J c-A.J iJC.t.A ( fq((CA olicy#or Self-ins.Lich�.-#'': I S i A Expiration Date: )1)Site Address: 3 Cnnrykvil\.r 'of r� -, ��n�s�y� I� City/State/Zip: O,)4 Io ] .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 Fup to$250.00 a da against the violator. Be advised that a copy of this statement may be forwarded to the Office of • tvestigations the DIA for insurarteloveragc veri cajion. do hereby certify un a ee ains adpenalties of'pe jufy that the information provided above is true and correct. i att re; d " 6+� / ,« Date: [ _y f 3 i ©l hone#: .�,1>!d•T -j. 7 7r'I X 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#: