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HomeMy WebLinkAboutBLDP&G-19-006286 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WOK II:tr'�— PERMIT#/�,OP`/�-� "�A % , . 3 CITY -- - --- MA DATE I )3 �L I Y ( �- OWNER'S NAMEI-�L AA- _Bui Tf LJ JOBSITE ADDRESS,��J_r����-_lane_ L OWNER ADDRESS L_S _ _ Tint 1 ---- -_____-__----_______-_.___I TELy? -� 4. I.1LC FAX TYPE OR OCCUPANCY TYPE COMMERCIALO EDUCATIONAL 0 RESIDENTIAL[ PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[I PLANS SUBMITTED: YES 0 NO FIXTURES 1 FLOOR- BSM 1 2 3 I 4 5 6 I 7 8 I 9 10 r 11 12 13 14 BATHTUB I 1 - i I -- I _ --- CROSS CONNECTION DEVICE MUM __ ® Wil NAM - DEDICATED SPECIAL WASTE SYSTEM I _ _-" 1 ' NE 1----11 DEDICATED GAS/OILISAND SYSTEM 1 1 . 1'. `'` DEDICATED GREASE SYSTEM �� , = DEDICATED'GRAY WATER SYSTEM i -!L_ _ 1 - 111111 iAr DEDICATED WATER RECYCLE SYSTEM ( _ _I I -5 - - " I DISHWASHER 1 DRINKING FOUNTAIN ®I 1 iI- 1t MOIMMIM -' - FOOD DISPOSER - --i 1 I `I I I r �- FLOOR/AREA DRAIN 1,M�._- WWI NMI __ .._.' INTERCEPTOR(INTERIOR) -- - -` t __ ,, I KITCHEN SINK 1 O LAVATORY :®IM� . . ��WMIMEMIMI"Ml --- ROOF DRAIN WIN��----� e. SHOWER STALL LM1MMM IIIII .M.—� - iiiiiiiiiM SERVICE 1 MOP SINK ��I®'l® l --- M URINAL _ 1—U�a® I IL- WASHING MACHINE CONNECTION =En IET— WATER HEATER ALL TYPES ,-� ®I®M WATER PIPING i [ [ 1l [ M OTHER - -- -- - C _ -_,` 11.1111111101111111111111111111- I�I.. ` I . -_ Nummil millmilonIMMimm. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[] NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LI OTHER TYPE OF INDEMNITY© 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 [J AGENT El SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are t 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 co ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I STEPHEN A.WINSLOW ___ ]LICENSE#I12298 SIG ATURE MP(� JP0 CORPORATION #I3281C JPARTNERSHIPLYI_ _-_ 1 LLC®# COMPANY NAME EF WINSLOW PLUMBING&HEATING__ ADDRESS 18 REARDON CIRCLE - _.—_- -I CITY SOUTH YARMOUTH __ STATE I- MA ZIP 102664 I TEL`508_394-7778___________._______I FAX 508-394-8256 1 CELL NIA _ EMAIL accountspayable@efwinslow.com • -- C l/ MP a Bab �C10060060i0000'6.6456606 41.1 1rd66.1.9[66.0610.9b66,9 Dep:,rrtrinent of Industrial Accidents i —II_ Office of Investigations ai.— d 600 Washington Street life s Boston, 16L4 02111 www Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers de s/Contractors/Electricia licant Information a ns/Plumbers Please Print Le ibl me(Business/Organization/Individual): c_rIns• (� dress: a. c, cv-) ,ae... . y/State/Zip: Scu ih crt"-vi,tin BA- Phone#: 'YO3-399.-1'77 csi you an employer?Check the appropriate box: I am a employer with -70 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or pa . have hired the sub-contractors I am a sole proprietor or partner- 6. El New construction P listed on the attached sheet.$ 7• ]Remodeling { ship and have no employees These sub-contractors have working for mein any capacity. workers'comp.insurance. 8' ❑Demolition [No workers'comp.insurance 5. ElWe are a corporation and its 9. T Building addition required.] officers have exercised their10.E Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 111.❑Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no — 13. Roof repairs insurance required.]t employees. [No workers' 2.—' comp.insurance required.] 13 C Other plicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. wners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tors that check this box must attached an additional sheet showing b the name of the sub-contractors and their workers'comp.policy information. 1 employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site atilt. ce Company Name: �y 6v i or Self-ins.Lic.#: 17,Ds1 A (�� L Expiration Date:_104- i— ail Address:__3 ems______ le,,` _i�1 1 City/State/Zip: t9��1(0 a copy of the workers'compensation policy declarationpage -1. ng the licy to secure coverage as required under Section 25A of MGL 152(can lead to theoimposition bof criminal penalties er and tilt date).) :o$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP $250.00 a day against the violator. Be advised t at a copyRK p nalties of a ations . the D A for insura • ,-overage verif , :on ofthis statement may be forwarded o the e ORDER and a fine ?by certify un a 1e sans a penalties o p-jury that the information provided above is true and correct. AL,.. Date: (a i ao`' 'al use only. Do not write in this area,to be completed by cio or town official. • it Town: • g Authority(circle one): Permit/License# .rd of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbin Ins ector er g p ct Person: Phone#: 1 , _, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS F!TT!NG WORK - '5_>=g =_";lit - � r ..f+�._ MA DATE /3_l C PERMIT# / 11L/.--oo lei ; ,, - CITY (a P 0 . ; . �z.‘. JOBSITE ADDRESS j_ o.h __eknr,_ __.__ OWNER'S NAME I_ J4-.)4,* Harl-te_r ._1 GOWNER ADDRESS , ._.___,L{4.ME_ TEL_._..._.______ -------- TEL 5-03.3aq-419(0,FAXI._..__ ._ . _.. _I TYPE OR OCCUPANCY TYPE COMMERCIALD EDUCATIONAL 0 RESIDENTIAL[(/ PRINT CLEARLY NEW:0 RENOVATION:El REPLACEMENT:[ PLANS SUBMITTED: YES Li NOD APPLIANCES 1 FLOORS-F BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER . -- I I 1 '_ 1 I-_ '---- BOOSTER _MI NO M1 1.1 CONVERSION E t I I__ Imo ` L - 1 -- 1 - COOK 415 DIRECT VENT HEATER muji L O,- DRYER �Imo__I _ --- I �- � i�l �f l __ 1 Q-- FIREPLACE MMM_MI'�� MM��-I- l_WIFM FURNACE.....4_1/4) - FRYOLATOR - _MN _ I __lir r---r—I' Mai 1---i IL _ _ 1 L_ -II _. ! I 1 GENERATOR• ._ L -_I _-II I- _ 1_.�J � .. ROOM/SPACE HEATER 111111111-MFMMIMIMIIMIIIIIIIIMINIMMUM ROOF iiiiIMNIIIMIMMIIIIIIIIIIIIIIIIIMMIIMIN HEATERTEST MINIIIMIMIlarillMinilIMPTS1111.11MMITESIM. WI UNIT MM.!1f 1110111.04 En I [ I11111IMMMI_____111.11111111 WATER HEATER Illiiimen1 Immt— I similmoiL Imulp&m....iainal: OTHER 111111111111111111111111.1.1 --'I "MMU_ M1_I_I-Hawaaa = ( IMI-_ __ .LL-:_ IMI. I®MOI __11_ 1�M1IM[ � L-___II ,I® - L. 1_� l L �C 7 I—C J INSURANCE COVERAGE W I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0 m I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW CY) LIABILITY INSURANCE POLICY (B OTHER TYPE INDEMNITY 0 BOND El i O- 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. Q CHECK ONE ONLY: OWNER 0 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 accurate to the best of my knowledge and that ail plumbing work and installations performed under the permit issued for this application will be in complia e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME_STEPHEN A.WINS.OW_ ___ _ LICENSE# 12298 SIGNATURE MP El MGF El JP 0 JGF 0 LPG'© CORPORATION Q# 3281C _ PARTNERSHIP DM , . _., . ,I LLC D# _. _, COMPANY NAME: EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE . - ..-... CITY SOUTH YARMOUTH _ STATE MA ZIP 02664 - TEL t508-394-7778, . I FAX I508- 94-8256. I CELL N/A , EMAIL accountspayable@efwinslow.com 'tea60 /4_ 7 /id• ZD-2\ 11/LLL G-+VO/11.e064l6IY¢.666616 VJ lIS¢QiyU 66L/y{qu Lyy0 _ fi Department of Industrial Accidents ' �1= Office '_;jni_ " f fi Investigations :�:i_ -� t 600 Washington Street i1: o Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/ rs A licant Information Please Printnt Le Leg ibl Name(Business/Organization/Individual): E Ic . i v-\j 1 e. Q( t U:Miro tLLnc � � .ec-Y-,,n- c'.':.: 1 fl l` Address: tic) taQ- City/State/Zip: 0,1 v1 cv^o-, ,,k„ HA-- Phone#: `508- 391r1'1n Are you an employer?Check the appropriate box: XI am a employer with -7O _ 4. ElI am a general contractor and I Type of project(required): 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 working for me in any capacity. workers'comp.insurance. 8. Demolition [No workers' comp.insurance • 5. ❑ We are a corporation and its 9 El Building addition ❑ required.] officers have exercised their 10.0Electrical repairs or additions 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 insurance required.]t employees. 13.❑Roof repairs [No workers' comp.insurance required.] 13.❑Other 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 check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site !formation. tsurance Company Name: w ;"kv --tiCA s k yIN` t,n ,o olicy#or Self ins.Lic.#: . 8 a 1 A Expiration Date: (—!___ (� ,b Site Address:D3 1nrvte.,i1 -e0--"1-y� C , �� ►V i IAA City/State/Zip: d)�}CO 7 .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 Fup to$250.00 a da against the violator. Be advised teat a copy of this statement may be forwarded to the Office of tvestigations • the DIA.for insurae• 'overage verif a on. do hereby certify un a ze ains n/penalties o jury that the information provided above is true and correct. i_natu?-. • iii wfli- —`.A. Date: (A , i ) ROiq. hone#: .. `ui, 7 27g 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 6.Other Inspector Contact Person: Phone#: