The URL can be used to link to this page

Home My WebLink AboutBLDP&G-19-001618 0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK __,�;� : ' .A'-4,2 e- T,/1-_. -< -_-.._1 MA DATE 9 J // _ PERMIT#/U-OP f/ /t¢ r �nukl= CITY�_-- JOBSITE ADDRESS C2$_..` ,...sul� n T_,T.fd, 7 OWNER'S NAME[ ,_ __O'S ,:. -..L ..<_.� i P OWNER ADDRESS _w- z J TEL56 , y6 li_Yd FAX ^.x_3 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL(R PRINT CLEARLY NEW: . RENOVATION:EJ REPLACEMENT: PLANS SUBMITTED: YES NOEl FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB i ; ,. ,I I. L _... ------r-.----I... CROSS CONNECTION DEVICE , ' I DEDICATED SPECIAL WASTE SYSTEM I `{ _;J - - I__— i —. _ — ._1__- , --_! _ _ _ :-_ i DEDICATED GAS/OIL/SAND SYSTEM l I s.. DEDICATED GREASE SYSTEM 1 ,.__._._._— 1 1 , -r*--- _�._ r__.__ DEDICATED GRAY WATER SYSTEM (`---" I i. .I._ I.. -_ I . . I 1 DEDICATED WATER RECYCLE SYSTEM I .__`i --r -- r— :-_ DISHWASHER IMIIIIIMMIIIIIIINIIIIIIIIIIIf 1111111211111111.11.111111* FOUNTAINDRINKING FOOD DISPOSER , - •-(INTERIOR KITCHEN SINK . ROOF DRAIN SERVICE/ •-SINK 1 , ,-;. TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I ..:- - w i ' . i ®®_ I I 1 r_ 1111111.111111111111 L INSURANCE COVERAGE: Li I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO 1, ? 6--, IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ii, OTHER TYPE OF INDEMNITY I 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 El 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 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 c pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. O ) D�...„ PLUMBER'S NAME .STEPHEN A.WINSLUW _____I LICENSE# 12298 SIGNATURE MP 41 JP 0 CORPORATION# 3281C..... (PARTNERSHIP,._4#. ...-. ....._.;i LLC D#1 N.___ COMPANY NAME I E F WINSLOW 1 ADDRESS I 8 REARDON CIRCLE CITY SOUTH YARMOUTH ti JSTATE I..„MAGI ZIP 1_02664-- 1 TEL I5083947778,_ FAX 1508 394 8256 CELL .ff EMAIL ACCOUNTSPAYABLE@EFWISNLOW.COM _K:._r_ _ _-y, , , � v,:, ify -( �['l��QI16nrag(� LjLLZ al:r , geiAccL6.m,�LC) } �1, L Office of ilave�ge.gjou 600 i%i asl'cuageunn SeFeei= r5 BosLob2,MA 02 177 axe www.Figokgov/dlig Workers' Compensation II our nice Arcadavit.Malklerfa/Contrzetores/Electrielansillambers Atgplicsmt Information IPierse Print Legibly .- Name(Business/Organizationhrndividual): E_c•t/u i,,\$ @v.) Zik), t`, i Eri.e.t.\- - 0 Address: F (6oicvi Circe City/State/Zip: Soo n\ Yot—c,.,k t4f3r Phone#: ) -Ytti -IT7Si . Are you an employer?Check the appropriate box: Type of project(required); ,..41 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 .„❑ I am a sole proprietor or partner- listed on the attached sheet.x 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g• El Building addition [No workers'comp,insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 1.❑ 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.[]Other comp.insurance required.] thy 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, :onlractors that checkthis box must attached an additional sheet showing the name of the sub-contractors:and their workers'comp,policy information. Ln an employer Malls providing workers'compensation insurance for niy employees. Below is the policy and job site rormation. E tsurance Company Name: tr"IY Y0:� ' rt•i kA 13%( ( CZ, Cod v i olicy#or Self-ins.Lie.#: \ 8 -l A- • Expiration Date: C-1 )b Site Address: .3 +1rvtcy.fl vet'a--0 Asy C 4 ,y \ City/State/Zip: 6,) f e 7 .ttaeh 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 no 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 Cup to$250,00 a daagainst the violator. Be advised that a copy of this statement may be forwarded to the Office of tvestigations the DIA for insurape/overage veri cat on, do hereby certij,untie e sins an penalties o peljury that the information provided above is true and correct ignatu3 : ,ram Date: 3 t a0 L b, hone#: -,c, .3111 7 7 7 is' 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#: • I ASSACHUSETTS UNIFORM APP!IOAs ION FOR A PERMIT TO FERF s RM OAS FI T TINO WORK -p -� illy- 7 • � CITY icy 0 /i-7 __.-. MA DATE_.�'-/3./i' ;PERMIT# P- JOBSITE ADDRESS 5, .Tyh„►,�,� S 4�c'7. IOWNER'S NAME ."..,TZo..f,--._.LL___` .. ,/.- -, ._t OWNER ADDRESS �9 '�j_,.__� w�.__ ._.-._ - y TEL' SDf d y�/iY�FAX TYPE OR OCCUPANCY TYPE COMMERCIAL°-„--i EDUCATIONAL ,�t RESIDENTIALA PRINT CLEARLY NEW::-_ I. RENOVATION:•._i REPLACEMENT: . PLANS SUBMITTED: YES -.,1 NO..,t APPLIANCES Z FLOORS-". BSM ._._1_._... 2 .3...__.4...-., -5.__....-6 ,_. 7...R. 8... ._ 9 10 11 12_...._..13_..t 14 BOILER `____I•.:___�.; .. ... . : - I. _.. BOOSTER y- : . _ -"t •_.�I:=._ -..:`` 4 ,...�.j`: t� -I'. __ �: CONVERSION BURNER ..1 .. ! i; r _11_,, . : I r I _.___1_.__I COOK STOVE DIRECT VENT HEATER i DRYER 111111111111111/111.11111111.11.111.111rMilifilkOMMIlli FIREPLACE 111111111111111111101111111111111111111111.111111111.1111111111111111111111111 FRYOLATOR11111111111111111111.1111111111111111110111111011111111.11111111.1111111111.11 FURNACE 1 111.111.11 ® .. . 11111111111111111 GENERATOR --� �� GRILLE INFRARED HEATER •,.-- . ININIIIIIIIii111111111111111111111111111101111111111111111111111111111111 LABORATORY COCKS 111 '. ,Y,,,I ® ® � 111111111111111111111111110111111110 MAKEUP AIR UNIT ® ®IIIRI ®SIJINIIIIIII-. - OVEN I -.a •,".. ;. POOL HEATER .-._ ®IMANIIIIIIIIIIM®_® ROOM I SPACE HEATER NINIMINIIIIINIIIIIIIIIIIIIMINININNIIIIIIIIIIIMNIIIIIIIMINIIINI ROOF TOP UNIT MINIIIIIIIIIIIIMMIIIIIMPIIIIIIIIIIIIIIIIIIIIIIIIIIMIIIIIIINI TEST 111111111 ®NIII® IMI®®M®MISI® UNIT HEATER IIIIIIIINIIIII®IIINA®® NIII®®®®_ . �E UNVENTED ROOM HEATER ®��® ®�®��®�....- WATER HEATER.._.. ;1/®®�� ®_ ®®® OTHER..._... .__ ._ .._._ .._ ._ I: 1. _ -- ..._.. 4 -. ....._ �-�� 1` Wit' -� I. .._..�' __._... :-------? `. ) of tt .......... 3.1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IL!i NO qy I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY !,._! OTHER TYPE INDEMNITY ..,J BOND L.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 ,,,..i 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 compli ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE#:12298 I SIGNATURE -i 1- IPARTNERSHIP._,...# - �.---- i t JGF: LPG' _ z CORPORATION # 3281 C , — LLC COMPANY NAME: E F WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE _ _ . _ _ ._ .._ TH. __ .__ . _._.. _. -__...- -- 4 STATE MA. I ZIP 02.664 ITEL 508 394 7778 I CITY SOUTH YARMOUTH "=_i Yµ--- -- - • - - -• " FAX:508 394 8256 1 CELL N/A l EMAIL accountsglable a Ins ow.co . . r, Depki°�'iaelld y®,j/Magenta AI CCI fi'fl�fS Office of](usve g&.4aor s W. , .... ; 600 lid JSMkggt® S ree Bogois,,MA 02111 • wwwomess.gov/die Workers'Compensation InsuranceAffidavit:l nnillders/Coffiitracctors0EIlecgrricista>ls/Plum Ders Applicant Informatio m Please Prim[Legibly .• Name(Business/Organization/Individual): E_C:.WtAs j ow Q(V 16, L V ��.� ��_, 1v°tC G. • Address: (teKydevi q Q- City/State/Zip: ,`,Soo•tmt csJ-t., c4A- Phone#: 0S-394 -1`77'Ci Are you an employer?Check the appropriate box: Type of project(required): ,,,INI 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.k 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 1.❑ 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 thy 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 chcckthis box must attached an additional sheet showing the name of the sub-contractors and theirworkers'comp.policy information. lm an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site yormaiion. tsurance Company Name: ',)3 cs-k0 i-IJO (,n j. et C kevi • olicy#or Self ins.Lie.#: Expiration Date: I---( ant-) >b Site Address:, 3 Cnnmei✓1 lMe 0-1 T h 01 CVQ, ,ld,�„ 11111� City/State/Zip: f„1 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 0.152 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 tat a copy of this statement may be forwarded to the Office of tvestigations the DIA for insuranet overage veri pc/Ion. orrectdo hereby certl wit e- yns an%penaltieso ur1thattheinformationprovidedaboveis'trueandc .iat3: 4 (7/1 r Date: (o't_ 3 i aO[ hone#: , 7_g•? Nt- 727E 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#: •