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Home My WebLink AboutBLDP-16-004694 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1m�• �CCITY ,1` .. MA TE E/7 PERMIT# ( P-/e9-049 1 JOBSITE ADDRESS / , n_SeW . OWNER'S NAME - (--- --j1C.1 sz, i d P OWNER ADDRESS —v...... __.. , 1 TEL_ °74,, FAX, TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL Li RESIDENTIAL B-- Nk CLEARLY NEW:Li RENOVATION:I[, REPLACEMENT: - PLANS SUBMITTED: YES NOZ- FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB • i --..,..' i i t.__ � CROSS CONNECTION DEVICE `�ail MUM DEDICATED SPECIAL WASTE SYSTEM 1011110111111.11 OM MN_ _am am aninalmigmosli DEDICATED GAS/OIL/SAND SYSTEM MIMI 1.11111111111111111ail IIIIIII NMIUM MN asuriesualigimum DEDICATED GREASE SYSTEM a _ am a am an _iMITI _ DEDICATED GRAY WATER SYSTEM MO NMI 111111 ME MN,__.. DEDICATED WATER RECYCLE SYSTEM gm MR _ DISHWASHER 1 . DRINKING FOUNTAIN 11 , i F--" ,, FOOD DISPOSER FLOOR/AREA DRAIN E • INTERCEPTOR(INTERIOR) xt1t.: P & .. L S S 7_.d 4--- KITCHEN SINK in iiIIMINIII LAVATORY ,. l ? I ROOF DRAIN i SHOWER STALL SERVICE/MOP SINK 11.11MMIMMIIMINMIMMIMIMIMMMEIMMINIWIMI TOILET a astsieram URINALa , . 1011 . ,. . _ _ r_ al . WASHING MACHINE CONNECTION MI I ;_ WATER HEATER ALL TYPES 1.110111111111111101 WATER PIPING . 11111111111.1011101111111111111111111111011111111,011111110111111111 OTHER i _.. ._ ,- ,I IIIIIIIIIINIIIIIIIIIIIIIMIIIIIIIIIIIIIMIIIIMIINNIINIBIIMIIIIIMIIIIIMIIMIIIIIMIIIIMIII INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 71 NO , , IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY?1_ OTHER TYPE OF INDEMNITY . BOND is 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 r AGENT L' 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 c•, pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4,, 0 4.„........, / ��l_ �_-e PLUMBER'S NAME j STEPHEN A WINSLOW LICENSE# 12298 I J�9�Z SIIGGNNATURaEc-6�i rv- MP 'j JP:1 CORPORATIONIi I# 3281C a_ PARTNERSHIPL# 1LLCCI#1 _ ., COMPANY NAME! E.F.WINSLOW PLUMBING&HEATING , ADDRESS 1 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA 1 ZIP i 02664 1 TEL 508-394-7778 FAX 508-394-8256 ` CELL— . EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM The Commonwealth of Massachusetts — DepartMent'af Industrial Accidents Ic_ it Office of Investigations ' �. _ 1 Congress Street,Suite 100 =iN=a Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E. F.WINSLOW PLUMBING&HEATING CO.,INC. Address:8 REARDON CRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I 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 2.❑I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance? required.] 5.❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c.152,§1(4),and we have no employees.[No workers' 13.0 Other comp.insurance required.] 'Any applicant that checks box Ill must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContmetors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees.If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic.#:1794 A Expiration Date:01/01/2016 Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine 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 of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of t IA o�r insurance co erage veri c�tion. I do hereby certi&un eriots and enalties erjury that the information provided above is true and correct. Signature: \ 6/L Date: 2016 Phone#: 508-394-777 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#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ►c_: _�6 'r:u1:�= ' CITY r MA DATE � ./0'/ PERMIT # e /)' /��/� q JOBSITE ADDRESS' _ ... r.. .. . hrt ../�:. i ... . ..... .. .. !OWNER'S NAME // ,... p, _,..,..... '- G OWNER ADDRESS „ TEL FAX PE OCCUPANCY TYPE COMMERCIAL , EDUCATIONAL RESIDENTIAL ' PRINT '')\, CLEARLY NEW: U,..,._,° RENOVATION: REPLACEMENT:,: . PLANS SUBMITTED: YES ....w, NO APPLIANCES Z FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ..- 1 ! .. .�J - -� BOOSTER E % 'i CONVERSION BURNER -. w-.._.. ►� COOK STOVE �._..:.. -. .... ,___ ....�....,.....:, w ti. 1 :». ..,.. . .w.. .:. J1 :.. , - ,,.;,,),\ DIRECT VENT HEATER _ f ; . I M ._ NDRYER I °..____ : .___,. _ . .... I I .. _ 1; N. FIREPLACE :- . :. w _ _ ... M I �: I � FRYOLATOR ____ _.1 :_,w..:. ..-....° ._. .,.,M: ._ - —.1,,.---1;. ...v mv... , '.uA t v.1' FURNACE �,.��_,. ! .,. ... A 1 . . :� , . i ., GENERATOR . . .... M 3. I . _...�.... . • GRILLE _ . _ w _. .-._ M. INFRARED HEATER LABORATORY COCKS _ J ..- _w _...... MAKEUP AIR UNIT t' _ _..Q w... ... .... _..�_ .....__....1 ..___.. w_... _. OVEN i .�-...�:._ .............__ _.�.. �..-....-. ._...M....., ._ ._.., , ... . .n...._..3 _.a......... ►; f POOL HEATER - }{ j - £} ROOM I SPACE HEATER ROOF TOP UNIT � : . ...s TEST . . . - UNIT HEATER UNVENTED ROOM HEATER i .... . M ,w. .,F _I , . s , _.3 ,. .___I _ .�:.i WATER HEATER ....:. .„, ..,. . ...:_j OTHER ______ _ , ,, . „.:._.. _ .. .1 ,„,..... .._ . ... :.M.. . . ..._......._. ..__...w_...w.. ...�w_w —_.�....._...__.._ .. ,_..... ...,� ._, .„ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES I .�j NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND 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 .....:' 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. Vd_..:L_ - ---iv ,......"„_ PLUMBER-GASFITTER NAME STEPHEN A WINSLOW LICENSE # SIGNATURE . : . . ... ..._.-.. 12298 MP .,. )UUIGF _,2, JP w... JGF ,- LPG! CORPORATION d# 3281C , PARTNERSHIP # # LLC # COMPANY NAME: E.F.WINSLOW PLUMBING & HEATING i ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA .ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 1 CELL EMAIL ACCOUNTSPAYABLEGEFWINSLOW.COM i ,_5"--10 : .4......:, C a (f The Commonwealth of Massachusetts w_ DepartMvnt'j'IndustrialAccidents le_- 1.ft Office of Investigations . ="•E Mll= v 1 Congress Street,Suite 100 =''itff a Boston,MA 02114-2017 ::z,,I www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E. F.WINSLOW PLUMBING&HEATING CO.,INC. Address:8 REARDON CRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): 1.❑■ I 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 2.El I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers'comp.insurance comp.insurance.[ required.] 5.0 We are a corporation and its 10.❑Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c.152,§1(4),and we have no 13.❑Other employees.[No workers' comp.insurance required.] .Any applicant that checks box#t must also fill out the section below showing their workers'compensation policy information. t 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 state whether or not those entities have employees.If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic.#:1794 A Expiration Date:01/01/2016 Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine 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 of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of IA or' surance'co erage veri cition. I do hereby certify un e- ins and enalties 'eerjury that the information provided above is true and correct ,— � 2016 Signature: c Date: Phone#: 508-394-777 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#: