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Home My WebLink AboutBLDP&G-19-000810 FD/ eU 3 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �4111 CITYL ✓L5 n ?// ece�/ i MA DATEI.... : ;PERMIT#,✓�/IF-1�r-��oSrdf JOBSITE ADDRESS ,r/5-,.:J w ,�_ !7l q .;.. I OWNER'S NAME -4s6/[1�tN ✓m>sLo ii/ __. 1 OWNER ADDRESS [ _3e __Cak.✓Tsiy ("b .)/2/1/4' .._ TEL SOT 34 e fool AX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL CI RESIDENTIAL PRINT CLEARLY NEW:1 RENOVATION:Lam1 REPLACEMENT: PLANS SUBMITTED: YES H j NO( FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I. CROSS CONNECTION DEVICE 1 1 i ..__ {_..._.. , DEDICATED SPECIAL WASTE SYSTEM I i .._.. __ DEDICATED GAS/OW I SAND SYSTEM 1 I ' I D- EDICATED GREASE SYSTEM (. I D- EDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM i ; DISHWASHER , DRINKING FOUNTAIN 1 ' FOOD DISPOSER i I FLOORIAREADRAIN I I I l.. I INTERCEPTOR(INTERIOR) I. I -I -- t _...__. KITCHEN SINK , I _ I ! I LAVATORY _1_..... ROOF DRAIN SHOWER STALL I I. 1 I I SERVICE/MOP SINK -- I i , I I i • I ' TOILET 1 _ I I - I I - URINAL I . I II I 1 I ' WASHING MACHINE CONNECTION I I I 1 I I I ' I p� I WATER HEATER ALL TYPES I / i L 1 ? I . 1� WATER PIPING I I ' I OTHER 1 1 _ I L. - } ( _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[I NO i IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I i! OTHER TYPE OF INDEMNITY 1 BOND 1. '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. i— CHECK ONE ONLY: OWNER i 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- a 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 liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / / t PLUMBER'S NAME STEPHEN A,WINSLOW ?LICENSE# 12298_, ,,, .,:.- SIGNATURE MPYI JP CORPORATION #3281C _.„..JPARTNERSHIPH•-t#[_ JLLC #1 COMPANY NAME I E F WINSLOW I ADDRESS 18 REARDON CIRCLE CITY!SOUTH YARMOUTH STATE r MA ZIP I 02664 I TEL 1 508 394 7778 FAX 4 508 394 8256 CELL I I EMAIL I ACCOUNTSPAYABLE@EFWISNLOW.COM _ _ ..._..,,_, ,I iy k iDeprr/.b's�?re�g c�,p-11L'aagi�'tL'�gull-E'Cgae'rIM V Mr 0,697ce , ..i,*.1 600 Vieishington Se , '-1,J. <i110 ww knCslligo idfi • l' orkers'Co er,pen;satio➢1Insurance Affidavit:B>t lders/ 'ontrractk®ns/EIectr icians/Plumbceit's A1p>1➢Bea.it%formation `-p Please Print Legibly .• Name(Business/Organization/Individual): E.'•W r�I e� QtkyxdOt �e.��' V 0_ 1/tt o Address: 5' (P i� C�rc City/State/Zip: •SoAt'0 Yor-w , Mik Phone#: '50S-3c14 -1`l. • Are you an employer?Check the appropriate box: Type of project(required): ,, %am a employer with '70 4. El I am a general contractor and% 6. 0 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,1 'l• ❑Remodeling ship and have no employees These sub-contractors have 8. El Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] . - officers have exercised their i.E 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.]t employees.[No workers' 13.0 Other comp.insurance required.] %my 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. ltn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1 rormation. tsurance Company Name: . / (`-‘v Iril 0.A :r\jsci.c,1 C P_ 0 v., v1ti olicy#or Self-ins.Lie.#: 03 A I A Expiration Date: k—[ _ au-) )b Site Address:, 3 Cann\c i a--14 , ) eGveA ,y1'^ 0.1�\ City/State/Zip: ( ,)LI LI,7 .ttaeh 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 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$250.00 a da against the violator. Be advised t at a copy of this statement may be forwarded to the Office of tvestigations the DIA for insurapet overage veri cation. r do hereby cent un e e sins an penalties ohm jury that the information provided above is true and correct. ignatui • 61„.c41 Date: i id 3 i 1 a0 L B, hone#: -.cbg•' `-i- 7 77X Official use only. Do not write in this area,to be completed by city,or town official • City or Town; Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other . Contact Person: Phone#: MASSACHUSE T TS UNIFORM'APPLICATION FOR A PERMV11T TO PERFORM GAS FITTING WORK _'= Jr., cat ,r-_E,-0tm'y� I. i -�� ="1i1=Q CITY . &) S 1 .... *. ; ••� .... I MA DATE 1-1.../� t 1 PERMIT#/�✓)�19 RO JOBSI T E ADDRESS:L5 icst,q,v is ...C° OWNER'S NAME •1SZ .vi.m,✓ _ ..6.s L ar�1 f GOWNER ADDRESS 3.1 1o4,✓ h`{ _.Ct.4 _.f'`fc. TEL___....._ TEL' FAX TYPE OR Y,$/L N,0 7 ,y i;;,7 y7 ie D?`7....( PRINT OCCUPANCY TYPE COMMERCIAL.i EDUCATIONAL; RESIDENTIAL )4 CLEARLY _ _- NEW:',.,,._I. RENOVATION::,__.1 REPLACEMENT:25i PLANS SUBMITTED: YES ,.': NOi.j APPLIANCES 1 FLOORS--0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER E. ---1:It] ,_...__... .__.... _.._. . `g : II BOOSTER ; r ._ 4F11 1 CONVERSION BURNER ;,..,....._.a` _J .,._..,wI .^.ji ._.w.a ......- 11 1 .-- � .I_ • I _.=.1 .... =' 1._.�..# COOK STOVE I. • ; I �.1 i 1.w,_...i I°._. I I! ' ... . DIRECT VENT HEATER _.1 I i i j 1 _ I' I j DRYER _._. ..._..�,. j I�...._•: _ J _ _ . FIREPLACE ,...w_..I ..--.1 -....: • j j� ,1__ l ..�._..i :... _..- ' FRYOLATOR ,! _i r .:..i; e w I i_. :i .,...,l. w FURNACE ' !_ I:.� ° .�.j •'. `gym ` .i I 1 1 GENERATOR J I '_ _- _i�..,_�_ -,.fit GRILLE i ' _____ .......,_..,J.w - 1, J. ._i ,.�_ 1 ... •�4.------� _ _...... I ' ..__. INFRARED HEATER _I i�� I two i _ _.M? E - - --- LABORATORY COCKS i ` _ , f I J. I I ' MAKEUP AIR UNIT �; . : „1• i I I 1 i 1 i OVEN l i 1., i' f L.. - - POOL HEATER i: 1 I. ;• '.,~ ..-J.i 1:I--- -.[.. ._. I._..e,. .._..—... ss_ ROOM 1 SPACE HEATER ((;,_.,-J ROOF TOP UNIT _ ,l: G .. ._1! , ice; .1.-„— ...�w�; ,--.° J . .. -,--, 1 TEST • l I • I ... ., r. 4 - •�,..1' - ---- UNIT HEATER `' i UNVENTED ROOM HEATER _.__._i I'm—IL- 1; I I ` ..1 -.,•-i ....--_--i I . - .. - p � WATER HEATER.- ... .. --• '...7 •I ... ._ :---J"J...- - ... ......11-1-. _ j 1 ._....,,..;I �l OTHER._.... .. ._.._ ._ _.._ ..._ ._ .: i. I. i. i, 1 -jl--_--.1 1- I L � ._ !--1 . 1 m t .. _ INSURANCE COVERAGE . I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IA NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY -,/,J OTHER TYPE INDEMNITY , ,J BOND Li 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 ;...:° 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 complian 'th 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 MP.., t MGF•.,_.I JP .ul JGF•.,LI LPG! 1 CORPORATION J# 3281C I PARTNERSHIP.,?:# I LLC _ #. . COMPANY NAME: E F WINSLOW PLUMBING&HEATING I ADDRESS•8 REARDON CIRCLE CITY SOUTH YARMOUTH a STATE MA }ZIP;02664 • • ITEL:508 394 7778 • • • ! FAX:508 394 8256 j CELL:N/A !EMAIL-accountspayableea efwinslow.com y � 1._,p4 DepedMeigg 011MTIOSinteg1,1CCWW.r Er ' tm_ Office ofllirav gcpao s Ilk `�' 7, 600 WeMiagionSimeg • .B0310109 MA 02111 • Workers'Con pennsatrti tin Insurance Affidavit:Builders/Contractors/Electricians i'iti mbers Applicant Info tioa, Please Print Le.:7b1i. • Name(Business/Organization/Individual): E.c. vv i,r,5 t ow Q(V,(o t,�e� 4. 0,a_lt-,) Ve.` t-c • Address: % J City/State/Zip: `Soa-1/.‘ Yerv-T-5-,hel 141r Phone#: G5OS-399-177 Are you an employer?Check the appropriate box: Type of project(required): ,, 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 ;.❑ 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. El 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.❑Electrical repairs or additions L❑ 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.]t employees.[No workers' 13.❑Other comp.insurance required.] lily 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. im an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1 is formation. ltsuranceCompanyName: .t} rt‘.11-iJOA LLIV 1�21,+'l \ t!11✓+,gov ' olicy#or Self-ins.Lie.#: `.3 Al A • Expiration Date: c—[ "- aOI-/ )b Site Address:,)3 CnnrvViil a--a Th t om°y Ot\eA4 NI City/State/Zip: ( ,,£Co 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 da a ainst the violator. Be advised t at a copy of this statement maybe forwarded to the Office of tvestigations the DIA for insurape/overage veri cation. do hereby certj,un e ?alias an penalties o pe jury that the information provided above is true and correct. ignat& ("4r Date: t o►. 31 ao L tr hone#: .ct `], 777X Official use only. Dv 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#: