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Home My WebLink AboutBLDP&G-18-002666 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK l , CITY / / 17/`f1 MA DATE 7/07 17 , IT# / t°044 M JDBSITE ADDRESS / r /4'/ OWNER'S NAME0� 7/1�' OWNER ADDRESS / Amemolow TELWainf AXI 1 TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL la- - 'kl PRINT .-.._ CLEARLY NEW:El RENOVATION:El REPLACEN ENT:ED PLANS SUBMITTED: YES 11 NOD- 'O FIXTURES T FLOOR—* BSM 1 2 3 4 5 6 Ell 8^ 9 10 ®® 14 Ii _ - CROSS CONNECTION DEVICE Mt,_,M` MI' DEDICATED SPECIAL WASTE SYSTEM ;E---1[M =1 MIE _ 11111I E DEDICATED GASIOIUSAND SYSTEM _-_ �, NIM C DEDICATED GREASE SYSTEM ,� 1ll1 _. il410 i� DEDICATED GRAY WATER SYSTEM M, I(-` I-. ,IIMIIIIIIMMMIVIIIMISITSIMMMI DEDICATED WATER RECYCLE SYSTEM MITIM-101 , _1 _ 1 __', _ � I � DISHWASHER - 1MI DRINKING FOUNTAIN ,; FLOOR IARE=A DRAIN FOOD DISPOSER I�. �;--_ �:� �� - --- I— INTERCEPTOR(INTERIOR ,�� _... ,�'.�!��M��M'.�! '#b KITCHEN SINK �__ ' � 1MMO LAVATORY ,��i' , __ _.� WI aw SHOWER STALL r r ROOF DRAIN _ . r 7 � f - �- SERVICE/MOP SINK '��!I__ ��I � ! I - _�_ _ i __. 1111111 �_- TOILET , , URINAL r 1 ,. _ . WASHING MACHINE CONNECTION l 1 T l r_ _ Ir ' WATER HEATER ALL TYPES ; ialla r__ _ WATER PIPING �� _ _.�; ��' 111 OTHER ,,,.�,,.r....,,_„ ___,_.son- — isam ._ ... r -. Hfir".",,,,-.`",T7T"--,7C-"-r",^- -.'-' I 1 r ---7---j INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES al NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0✓ OTHER TYPE OF 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 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 co ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��\J i f-,- yam/ PLUMBER'S NAME 1 STEPHEN A.WINSLOW !LICENSE# 12298 r� �e SIGNATURE MP El JP® CORPORATIONI✓ # 3281C PARTNERSHIP# _ LLCQ#I 1 COMPANY NAME[EF WINSLOW PLUMBING&HEATING ;ADDRESS 8 REARDON CIRCLE CITY'SOUTH YARMOUTH I STATE MA ZIP 0d.2664 TEL 508-394-7778 ' FAX 508-394 8825Ej CELL NIA I EMAIL bccountspayable@efwinslow.com 0 e l'f 9 b'A 6' j .o Department of Industrial f1cctaenrs l'=c,i__- Office of Investigations • =i lir? 600 Washington Street \ . _ Boston,MA 02111 r.,?r www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information /� 1 Please( Print Legibly Name(Business/Organization/Individual):E.C•Ww•451 Q,.l Okh,.. ike+cj L o t0.t,✓ , `m.)del(• Address: QQeodcsn C I- (J a City/State/Zip: Soo$h mks Nir Phone#: �O0-39ti-11?S 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 * have hired the sub-contractors employees proprietor(full ietorr or pparartner- listed on the attached sheet.s 7• ❑Remodeling ;.0 I am a sole partner- ship and have no employees These sub-contractors have 8. 0 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 10.0 Electrical repairs or additions required.] officers have exercised their right of exemptionper MGL 11.❑Plumbing repairs or additions ❑I ys la.[No workers'ree doing all work g § ()P 12.0 Roof repairs myself.[No comp. c.152, 1 4,and we have no -, insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] tiny 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. :ontractora that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. dm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site rrmation. _ (� isurance Company Name: (KY yO•,.s C\4-)�v aA ,_ 'tN 1u el(e- ` o cvvi olicy#or Self-ins.Lic.#: `' 'I A • Expiration Date: , l— aoi 7 )b Site Address: 3 till c—(T Ad'ai Ch 114' I t M1 City/State/Zip: 0,)"-1 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 • f up to$250.00 a day against the violator.Be advised t at a copy of this statement may be forwarded to the Office of tvestigations b..the DIA for insura�le- overage veri ion. i do hereby certtijjr an.' ns an;penalties o pe jury that the information provided above is true and correct. ignatu?es (. Date: i DI 3 I)9,0,5" hone#: .511i•3`r 727d' • 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 l_ CITY [`'f; T Y �_..__.. . .____.. .... .� _._ MA DATE L ' . ':L; ERMIT# 11l - ;-c' JOBSITE ADDRESS, / ? iJ4 'i/' /2&t' I OWNER'S NAME G1T# , f 7! d OWNER ADDRESS �� TE M1,�. 'fL'I1 TPRI NT OR OCCUPANCY TYPE COMMERCIAL EDU ATIONAL RESIDENTIAL /r C CLEARLY NEW:E t RENOVATION: D REPLACEMENT: 1, PLANS SUBMITTED: YES ED NO FrAi- APPLIANCES 7. FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 � BOILER ' �Li -_M 'Nialliffillitillill10011111111111110ININ _ � .J r BOOSTER 1.1.1111111FillWili~- -'L MMWOIM __ CI- h_ CONVERSION BURNER n_LIMM11111-77: M��_ .COOK STOVE -- `.. DIRECT VENT HEATER Imo. _ — DRYER _ __ill_ ___ � �� iiii-111111Mil ' FIREPLACE — -- -- -- - ' V-1 --7.- ! - 1� -- FRYOLATOR •- 7 _ -- - - I-- FURNACE � I __ ' i__ - I�I�� M M� GENERATOR l �_ : ._- ' _11 -r� !:�EM1 GRILLE �� T M1i INFRARED HEATER ��. i- -_ - � l .. ...-.I-. . � TTTL1 ..LABORATORY COCKS �� . � I - � � �� ' < 1101 MAKEUP AIR UNIT _ ___�_. ��'� - (' - '_ � -- � - -- OVE N �I '. ..._ ILJ�L 1L J -"�(I �__IUS POOL HEATER �I�I-� . ' 1- � ROOM / SPACE HEATER I - i I - '�'��W M ROOF TOP UNIT 111.11M1111101.. . _`i IW�M� 'I - l TEST =1111,111111. 1111 -UNIT HEATERI -- UNVENTED ROOM HEATERPlI_ _^''L_�� ,r- eigiumAil WATER HEATER . _ _� M� ._-� �_1�� IM OTHER _ - - - ` .._...._7 I I .-.� _ I : imiellifiCM*0 ,1-7: Jiiiiiiinatalli------.M.111. 110111MAili — __ INSURANCE COVERAGE I have a current liabilit insurance policy -or Its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [ NO 1 rr liability_ insurance IF YOU CHECKED YES, 'LEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E 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 D AGENT D SIGNATURE OF OWNER OR AGENT I herebycertify that all of the details and Information I have submitted or entered regarding thlstiap willation be in ace true and accurate all to the-best provision knowledge the and that all plumbing wo d Installations andCpte performed2 ofder thetGe permit Laws Issued for this application Massachusetts State Plumbing ' '- ' LICENSE #rr 12298 SIGNATURE ER NAME STEPHEN A. WINSLOW SLOW 112298 , GI CORPORATION r '# [ 281C PARTNERSHIPS# LLC D# :I MP � � MGF�, JP �� JGF D LP „_,� �. ,�.. �,- -- ---. _ - 1 COMPANY NAME: EF WINSLOW PLUMBING & HEATING „.1 ADDRESSElpiON CIRCLE ..,..�.. �`"�` � 'I STATE MA ;ZIP 02664 jTEL � 508-394-777� CITY SOUTH YARMOUTH ---... FAX 508-394-8256 CELL NlA ;!EMAIL 1,accountspa able@efwinslow.com _- _ __ __ - ..-_ . _ .. .__ . - - _ ----- *__ Department of industrial Acctaents '=_,� 1_AV Office of Investigations rE,Tin'? 600 Washington Street ` i= Boston,MA 02111 y -�' www.mass.gov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information C Ple(asse Print Legibly • Name(Business/Orgganization/Individual):E•C•Wi�sIOvv Q(V��Okru� &�t0. ,11 `m.,I°1c• Address: tCPo � C�ca.0.— d City/State/Zip: Soo c o 'o.-k MP Phone#: `50b-3`l1-1'7?Ci Are you an employer?Check the appropriate box: Type of project(required): /tEI 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 Remodeling ;.El am a sole proprietor or partner- listed on the attached sheet t7 g ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5.0 We area corporation and its 10.0Electrical repairs or additions required.] officers have exercised their 1.❑I ama homeowner doing all workrightexemptionper of MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs 1, insurance required.]t employees.[No workers' 13.0 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 anew affidavit indicating such. :oyntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. rim an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site 1 M1`ormdtion. - isurance Company Name: Mirror..) C-kJk01 .. 5U2leA(..Q_ 0 aU" k'^`l olicy#or Self-ins.Lic.#: I$A I Pr Expiration Date: l--1 Doi-) )b Site Address:, 3 Gr"ran n_11 A/ C6 2,7 ,14. I ' City/State/Zip: 00 W to 7 Bach 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 f up to$250.00 a da ainst the violator. Be advised t a copy of this statement may be forwarded to the Office of vestigations the DIA for insure overage veri a on. do hereby certify un ens an penalties o pe jury that the information provided above is true and correct. ianatu&• ,. r Date: 1 DI 3 I 1 aO1 hone#: S-Ut-154•777X 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#: