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HomeMy WebLinkAboutBLDP&G-18-003654 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • li:Nn''_ �,( ° MA DATE (Z %P> /, PERMIT# P/� a_ _�►I_.,:• CITY /t'rL iiWt) Jo®SITEADDRESS°t/ r /fin 1 OWNER'S NAME /a/ 7Ie �/ OwNER ADDRESS f'V)(Li�/� 1 TELL f//.k T� 1 f 1FAXI, 1 N TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL © RESIDENTIAL EL ...- PRINT CLEARLY NEW:© RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES C1 NO 112 FIXTURES 1 FLOOR-+ 9 •1 2 3 4 1 5 6 7 8 9 10 11 12 13 14 BATHTUB • T'- .-1... ._ill.,_ ,,._i_._ CROSS CONNECTION DEVICE. ?'• i. DEDICATED SPECIAL WASTE SYSTEM 'Li DEDICATED GASIOIIJSAND SY TEM NI. i ni � DEDICATED GREASE SYSTEM0 PIIPAIIMM �� _ l' INI DEDICATED'GRAY WATER SYSTEM ' i �OININaillitlilit� eplimi DEDICATED WATER RECYCLE SYSTEM 1!l111�e' _• DISDRIHWASHER OUNTAINI) � FOOD DISPOSERIIIIIIIM1 FLOORIAREA DRAIN PM 11.1101110111111011111111ININIIIMCIIIII111111 ! : ;1111101K1111 . lb INTERIOR ��[���� KITCHEN SINK , 11 LAVATORYMICIIIIMIIIIII MOM � Oft .MNPMIN PO. . NIC ROOF DRAIN �1 SHOWER STALLM 'I NO SERVICE I MOP SINK MUM* �"�' lilit � �' �niK��'Pig NM TOILETPIIIIIIIMIlltilligmlf .1.111101111.11111111.00.10--- WASHING MACHINE CONNECTION iimi ugg migank apt pm o_ OTHER .. , WATER HEATER ALL TYPES � ! '�' il� � 111110 � � � � -- WATER PIPING ---.......... .._.-_. .._ �' � INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 12 OTHER TYPE OF INDEMNITY® BOND 0-• OWNER'S INSURANCE WAIVER:I am aware ei natuhe licensee e permit application insurancen this requirement.ocoverage required by Chapter 142 of the Massachusetts General Laws,and that my 9CHECK ONE ONLY: OWNER D AGENT SIGNATURE OF OWNER OR AGENTand accurate to the best of my I hereby all plu bi all of the details end Information under the submitted permit Issued forregarding thl application application willl be Inare corn true nce with all Pertinent provision of the knowledge and that all plumbing work and Installations performed Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 12298 SIGNATURE PLUMBER'S NAME STEPHEN A.WINSLOW _ LICENSE# 2298 1]" MP13 JP® CORPORATION S]# 3281C - ,PARTNERSHIP[ #MN LLC©#L • COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 RE CIRCLE CITY SOUTH YARMOUTH STATE 1 MA ' ZIP 02664 TEL 508 394-7778 FAX 508-394-8256 CELL N/A EMAIL accounts a able efwinslow.com aceparunent of lndustrialAccsaenes _''ill=;' Office of Investigations 600 Washington Street 1 Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information /� Please Print Legibly Name(Business/organization/individual):E'F•Wr,1$te,,.t Qlkiv,IcAvx6� ,& e.R c'e)I✓1C, Address: ' (4erann C s Q_ City/State/Zip: Soo.vt , c,,(-1,, (`{Pc Phone#: `$0S-3c19 1r7CJ 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 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. 0 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.❑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' comp.insurance required.] 13.0Other hny applicant that checks box 8l 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 subcontractors 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 "ormation. I isurance Company Name: ? ( r3v,,J (`�j t t/0--4 ll am 091/vs VILi olicy#or Self-ins.Lic.#: \' 1 I A. • Expiration Date: I—1- au-) rb Site Address:,)3 rv.n an woe a-1}71 A s iay ae3114' M C B City/State/Zip: O "-I to 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 lup to$250.00 a da Against the violator. Be advised t,:t a copy of this statement maybe forwarded to the Office of ivestigations t e DIg for insurarie- overage verb a on. do hereby certify un a airs an%penalties o'Fjury that the information provided above is true and correct. ignati r'/ " ` Date: [dz.)31 I a0l�• hone#: S[)A.3ly-7 77X 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#: Si. r_____. / MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ir CY CITY MA DATE[ . ---- -,..... _ ......,. /2. ' /El 'LLIPE/MIT# ii Ad:1217—iirt) /,3&' f a JOBSITE ADDRESS / A Stitrh _. T I OWNER'S NAME , G OWNER ADDRESS II. T. 4 Ai '7 Alk 1 TEL (-1/ 3 6 (// -9' iFA).(1, 1 M .._.... ..... .. . _ .. .... . . _ _ . . . . ...... _ ... . . .. . .._ <4, TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL :1 RESIDENTIAL CLEARLY -- NEW:El RENOVATION: ai REPLACEMENT: El PLANS SUBMITTED: YES APPLIANCES 1 FLOORS--* BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BOILER 7 ..................... ..............--.'..—..........—,•-i......-...—.-...., .................--...—...,............ ..---7-......-... I sil — - - -1 i-- ii:771. - -...i BOOSTER 1_ . ;1_ - I—. CONVERSION BURNER r• I I . 1 _it . _ 1 ii , --1 . . I i I .1 . . .:, "O. COOK STOVE _,._,.__. .:i. . • . 'I 1 . 4_. . ll . \I._ . .. Ii .. . i H . I . . . . 11... DIRECT VENT HEATER : : i --71---ii-----i. r—iti—"•—1------ 1----1 —1 --T---17- _ - _ _ ....._ .... . . , _ . .... .. . . .. ... . .... . .. .... . ... ... .. __ _ _. _ _ ._. ...._ . ..... _.. . DRYER . . _ ._ _ _ ._ . . . ._ _ _ FIREPLACE .. .,_.. ._. . . .... : .. t . "1 __..!1_..„:___...) _ _____J ,1 I FRYOLATOR __ . I . --.q .. .. .1r."--.717.77. 1---. 7--, . . -.1 -. FURNACE -----.' -----7 c----71-----!1—. ,-.'-- 1.------- 7---- t------71-----'-i----7----1,'--- i—T77—. GENERATOR _ _. . . 4 i !, ti 'I i I i I - • GRILLE . • ;- ---r——.' 1---''----r1---..--11". I I 1.1 . . 1 'j- I' 1. . . . . . . - INFRARED HEATER :.: .....,,-- __—,---__ - -- ----- ----,',--- ,,—"---'7.----',i---:1---1----- j. -l'—'-1.- 1 ' !1 - . ._ • . ,_ • _ .e 1.. . • 1 . . . ! . .. _. ..._ . _ •. , _. . ... . .. ._ ... • ,..____. . LABORATORY COCKS - 11. . U. 11 . 1 _ .'I . . 1. :: •-•-....al . ' MAKEUP AIR UNIT I -- OVEN 1 _q . A. ._ I . y, q„ . .. -.-_-...:.___Th ...L_-...y- • , - •--- --- ...____-_::__, -....:-__La.-.__ , - - .___-. • ,-....... ...-......;.. _ _- ____=:_-_,L. -.POOL HEATER ' I . `,, . . i • ;I __II.. !i- -) _ . (I ( f ! ROOM / SPACE HEATER I . .•,..- . .:..,.-...z.i '1 • -- .:::_z_...., ..... -__:_:......... :_:._:.._...,_L.•_:...__,...„.......;___.__..-.7-7,--_,.. _.L...4.... .-..L__:, ---,:---:--:----;*,:-------- .„_______ - . - - - - •I_ 'J—.1---: ------ ---. i _ 1 1 . _ 1E767 ..- TRE0s0TF TOP UNIT . : -. :I.. . .. i I_ . _31. ... ,I. ....IL.. . . . 1., ...: . 1 _._i. __L. H UNIT HEATER I ;I !.I. . ',.I , i _ . . _ cl_.. 1 „ I . . 'I . i,.. .. . I 'di.. .. . • UNVENTED ROOM HEATER ' _LL- .. .........z..__ • _ L.._. - ___-_:_....---__:_.-,;_..,., .._______ - WATER HEATER - 1 II . . ii q . —.. . . .i ----. . 1 71 . Ii . I. .. ..I. . ..! . 1. _,!. OTHER !-F----til - —71 ---7 ________ . . . :, . 1. . . ..1•1.. .. _A . : .. _,. . .. . li. .. . .i.... ..A.._ . . . —__:.1. _. .1 II._ 1 • :1 [---- .1 d 1 1,; 1 . . .._ il . ,1...._ ii . ....L, .. .I .. . .... : , _ ____. ____ ______ *.-.......-.. ...—••••........dn. •J..6,4•...,.- Er L,..„.. . „.„_, .,.. _...21: .. i,.,_.,...' [,,_,... 1 t....,; „,[1.....:E.7,-L-.. -'. INSURANCE COVERAGE I have a current liability insurance policy -or fts substantial equivalent which meets the requirements of MGL. Ch, 142 YES Ei i 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 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 0 AGENT D 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 complia,nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. " ----;6-/-1 I-, ,,_,, f://t//,• Zad., . PLUMBER-GASFITTER NAME LSTEPHEN A. WINSLOW ,... 1 LICENSE 4;12298 1---\* I SIGNATURE MP El MGF D JP El. JGF El LPGI .11 CORPORATIONE/7# 32.[T16.—; PARTNERSHIP Elit , LLC D# 1: i COMPANY NAME: EF WINSLOW PLUMBING & HEATING ,I ADDRESS 8 1 -CRDON CIRCLE —=___I- , ,........_ .., CITY SOU. HYARMOUTH... ..= __ ; STATE FAT ZIP 02664 'TEL 1 508-394-7778 ..----- .....:,: . _ , • ., AX 508-394-8256 . CELL N/A !;EMAIL Lzj2aaclajole efwinslow.com F _...,....... .. ...,_ '/ Department of lndustrt al Accutents Ir= t._4'/ Office of Investigations ='in1=-; 600 Washington Street = F 'cif= Boston,MA 02111 . — ,r` www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information f t� 1 Please(� Print Legibly Name(Business/Or/ganization/Individual):E.'C•W,nslot,.i Y(Vo-.Oi✓te� 2`at0.1.. `e.,�✓lC. Address: '' l`<P trdtsn C i rti - City/State/Zip: Soo h o-,c,.31,+ MPr Phone#: '50a-394-117C Are you an employer?Check the appropriate box: Type of project(required): I am a employer with •70 4. 0 I am a general contractor and I 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.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. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 1.0 I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c.152,§I(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other buy 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 theirworkers'comp.policy information. din an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site Tormation. isurance Company Name: A C Y)..J Cr*,-)k t?-jl f I.MGt el C2 \ O.1nGt✓l--1 • olicy#or Self-ins.Lic.#: I P A] .A Expiration Date: C—]" adi-) 1b Site Address: 3 Corvr"raflw-ea--1{"h > y aNeAvA. 11A City/State/Zip: 6,)1:467 .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 roe 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 t a copy of this statement may be forwarded to the Office of vestigations the DIA for insurace�roverage veri i on. r // do hereby certify un a ains an penalties o pe jury that the information provided above is true and correct. ignatut �___ � ,,c Date: l-.)31 l 9,016 hone#: .STA n't-7 77X 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#: