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Home My WebLink AboutBLDP&G-18-003139 rcj? .04 MASSACHUSE T TS UNI ORIVI AP'PLICATIONi FOR A PERMIT TO PERFORM PLUMBING WORK �o . k"_. ��'- CiTY� �E 5 T V�R�Q� ` MA DATE -Z/-�/ 'P RMI #/ J JOBSITE ADDRESS 1l 0c,(!pkct 4_44 _I OWNER'S NAMEC,[ /ly c dr S.OQ6 Lk,v ce i 0 OWNER ADDRESS,o_ __ — __. 1 TEL .;11.1 . FAXI TYPE OR OCCUPANCY TYPE COMMERCIALL EDUCATIONAL D RESIDENTIAL® PRINT • CLEARLY NEW:J RENOVATION:D REPLACEMENT:t1 PLANS.SUBMITTED: YES[' NOD FIXTURES 7- FLOOR--} - BSM •1 2 3 4 5 6 7 8 9 10 11 12 13 1.4 _:ALL_=_-_-[71-- 'L.,..:-.i E-11. =1� ---- -$- BATHTUB _ ___ CROSSCONNECTIONDEVICE ,_I(•- 'L ___-'; -._;(-__fir _.11 xI'? -.: 1_:-..-:--[-1-•--`1. _ _� DEDICATED SPECIAL WASTE SYSTEM r--,.. �L:., lr-_ _.. r--.J -.-�:1 :.+1-=--•-'I - {E-_L==I:_._ it �---- - 6j ._•, t DEDICATED GASiOILISANDSYSTEM f -l-_ :i-.,`1--: 1.... • 1 _ {17-- `' ��MEIM DEDICATED GREASE SYSTEM 1,-- l- � ,I. 11 . _.l l,_-a,11_. - I__:- (__,A J.._-_ll-----' DEDICATED'GRAY WATER SYSTEM ['1.-- F ✓.r_., r. (lz-;�: L_.,:_JL. -=3 `,�. ' -{ DEDICATED WATER RECYCLE SYSTEM riET'L`-_,LIT [::_._l[-==)I_�., ,: ETD F.,-s L- =_. I,-__.::) DISHWASHER - I- .. .'I _ - :L- E-_:11_ll> .-9� L-::.__�_�cl-,`r.._.:-:.1 DRINKING FOUNTAIN 1- ..-__'1- �._. I_ _,1- .:11 2_11, -47.ti ' �:1:: FOOD DISPOSER •• I '1I.,,_ . r7.:-'.r_ ;1771T11 i ... r-•yll__71 - .__;II FLOOR I AREA DRAIN -.--..= ..--° --- N; �'{ INTERCEPTOR(INTERIOR) L--.°II__,_:: II-. -.1�_,.-} -s 1r-.-. ,'1 ,1._. L .. .i KITCHEN SINK T_ -II _II_- I. '.1-----il _ _..11. :il-_t.L- • ;r---•__l LAVATORY L_JT-::il:_ ,1---_,L.-.-:11-11:.:. :y�. ,1-y''I._ •-` Altai ROOF DRAINil7 -- - [� SHOWER STALL r- 1 L:::.,..._1.-., i SERVICE I MOP SINK E :::;:::':.' `! ® URINAL r ;1•__1 ,.-.._:i - -[ - - _ G MACHINE CONNECTION - WASHIN -- - . T[ -- "-_ .Illi . , ALL TYPES 11 .I.... 'Ls � - WATERHEATER `I 3 T -._..--A -I _�[7 -:-- .- .I'I WATER PIPING I,T--Ir- 1-J��Jr-'.. �1.--�.--�.-:. _ 1. 4 OTHER --=1I-,,�,r ;r-`-. ��' ;l~ '1•..._. 'I- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO Li IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY 0 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 D 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 an•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 comma withall Pertinent provision f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I,STEPHEN A.WINSLOW _ j LICENSE# 12298 I SIGNATURE MPD JPD CORPORATION# 3281C _ IPARTNERSHIPE'#I ILLCD#1 COMPANY NAME IEFWI�W PLUMBING&HEATING 3 ADDRESS 18 REARDON CIRCLE J ---- CITY SOUTHYARMOUTH i1STATE MA]ZII? 026844 TEL 508-394-7778 —, • EMAIL Laccountsmable@efwinslow.com ^�-- � � FAX 508 394 8256 I CELL NIA � ___._p_ Departknent of inanstriat Acel engs Z r i Office"Jf�iwestiguxlorvs fi fl 600 Washington Sheet 11i� Boston,MA 02111 wwvArnass.gov/dia ' Workers' Compensation Insurance davit: n,ildeus/Contractora/TflectriciansfPlumbers y1 licant Iforinaton Please Print 1Legj iwme(Business/Organintion/individual): E,c. inS�oN SuA.,stJi✓l ° E�� . VG-t ItCe� al � • dress: r t r/State/Zip: Soo iti Yc'ru'. - , MA- Phone#: S�8-39 9 r-1'1'/ • you an employer?Check the appropriate box: I am a employer with '7� 4. Type of project(required): ❑ I am a general contractor and I •employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction I 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. [No workers'comp.insurance 5. El We are a corporation and its 9. [II Building addition required.] .officers have exercised their 10.❑Electrical 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 12.❑Roof repairs insurance required.]I employees.[No workers' comp.insurance required.] 13.0Other pplicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ;owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. actors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. in employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site I nation. ___ nice Company Name: ("tv a"t1 o�j ` mrC4 .e \ olp","..►`i — - #or Self-ins.Lie.#: 03 A I A ^^ • Expiration Date: —1 t p(`) ate Address:,3 CMr.Acrv1 cr-( t ,/ C W.S 1 11 City/State/Zip: ( ,7146 7 h a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). e to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a • p 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 . to$250.00 a da against the violator. Be advised t at a copy of this statement maybe forwarded to the Office of igations the DIA for insurapeeoverage veri ca ion. ereby certify un e e airs an Penalties o J J � Pe Juty that the information provided above is true and correct. ::&ei - L^-- 7 4 ,s ue Date: ( 13 i I ao['5' #: .si)St•2,N 7778 • ?cill use only. Do not write in this area,to be completed by city,or town official • • y or Town: Permit/License# ' 1 ling Authority(circle one): board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector )ther • itact Person: Phone#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .._"I_l� CITY ; (4/!fs ye w ew.)4 O.Y 7.d, .,. 1 MA DATE //:2/-/) , PERMIT# /,�l-,l9i9'/ ' JOBSITE ADDRESS; 2/ A4q s Dk c/'[ip,,✓i (OWNERS NAME /My ct ,,,,,<0A"I k fro( l GOWNER ADDRESS /P.� .__,.. . .., , I TEL SOP 3 I Y.7 rte(FAX TYPE OR OCCUPANCY TYPE COMMERCIAL'.;1 EDUCATIONAL w ` RESIDENTIALXI PRINT :.,J........ CLEARLY • NEW. . RENOVATION: -._.f REPLACEMENT: 4 PLANS SUBMITTED: YES_.__1 NO`,_-,; APPLIANCES Z FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 • BOILER ' .._ _I. _i I' 1, 1_.r. BOOSTER r 1 , CONVERSION BURNER _J.w.. .1 , .._.; 1. _ . .I__.._ _ COOK STOVE I____ ..._.w I._._., al : _ 1,_.. _ DIRECT VENT HEATER __ ,,._,. .. ; ,. .. w .i'r __I DRYER FIREPLACE 1__I , ._..I �..a.._» . ._. ._. ,..1,_ ,,._._ . 1 ___I_ _ _ ........„..1_ I.._._-a ....__i FRYOLATOR ' _ -= i it FURNACE ._.,..w._ . ,, i ,_„1_,., I ._. ,,,>I_:.,....,.. . _W._:l GENERATOR GRILLE _ - INFRARED HEATER I _ : ;__. a__ LABORATORY COCKS I 1 ,n... MAKEUP AIR UNIT w _, _ 1 _ I : OVEN _ t __��- POOL HEATER 1t I. I 1 , I t I . ROOM 1 SPACE HEATER t, ____I .... . 1 -r_.. I I . .. ._i J ROOF TOP UNIT 1 I i I _I__ _ ,__i 1 1 . ___I , ..„i L. TEST i_. €. ... I I . .... ':� __1 __ UNIT HEATER ! - I _ _.... ` UNVENTED ROOM HEATER I i 1 1 { -- WATER HEATER..... I I _, t _ ._.. _ 1 1, 1 _... \, OTHER ..... .. . 1: __I. l__ I __.I m . y, J j t i _..._ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO _. I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY '.1 OTHER TYPE 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 : AGENT ... SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true d 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 comp' with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW _ j LICENSE# 12298 SIGNATURE MP MGF.__I JP _,.1 JGF:._: j LPG! ,I CORPORATION + # 3281C PARTNERSHIP `# I LLC # COMPANY NAME: E F WINSLOW PLUMBING&HEATING (ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA I ZIP 02664 j TEL 508 394 7778 FAX 508 394 8256 I CELL N/A (EMAIL accountspayrableGa efwinslow.com a. bf- ‘i° 1.4!P i, Department of industrial Acctaenrs tr 5yai i= !l Office of Investigations i...in!=. 600 Washington Street ' -' _':�i`= Boston,MA 02111 • -.i.e., IYIY .ma s.goI/Kia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information nn i • 0Please Print Legibly • Name(Business/Organization/Individual): e,c• V V 1 v S 1 eve `�1V v Jo w,c{ L 0{,p�\,1v. vit. Address: ic a.,eenatvi C st t1 - City/State/Zip: Soo k+1 Yci'v-^G•,T MAr Phone#: 50S-39`1-117 Are you an employer?Check the appropriate box: Type of project(required): ,,,NrI 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 .0 I am a sole proprietor or partner- listed on the attached sheet.I 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their i.0 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' 13.0 Other comp.insurance required.] t.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. :ontracto s that check this box must attached an additional sheet showing the name of the sub-contractors gad their workers'comp.policy information. Im an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site lrormation. tsurance Company Name: A T(0••� rkv IrlIcLA j_inyurck ii c2 CeV"` 0,i olicy#or Self-ins.Lic.#: `$a l A . Expiration Date: k-1 — anl1 )b Site Address:, 3 r+'cY" J e°-3 A , Ce3 ` 1 `1 City/State/Zip: O,) l (::::2 .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 tie 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 at a copy of this statement may be forwarded to the Office of • tvestigations the DIA for insurarpe overage veri a`�ion. / I do hereby certify un e airs an penalties o pe jury that the information provided above is true and correct. i at&ei- -__ < "' r-jk" Date: (oI 31 I a01tr. hone#: .S171•354- 7 7 7 g 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#: