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Home My WebLink AboutBLDP&G-19-001443 gcV_ .�- I' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK AIi7� CITY I,._. a .e 4. 0/4_.1 MA DATE[..:.?._‘. /GP `PERMIT# .OP- ?-CO /y JOBSITE ADDRESS i✓Lf .,� 4_fe .:,.. .__1 OWNER'S NAME%_R 4t3��...�_ , - ..:f POWNER ADDRESS _ 7''I L_ , T _._..�__. _ _:{ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E] RESIDENTIALPS PRINT r--� CLEARLY NEW:L I RENOVATION: REPLACEMENT:[ PLANS SUBMITTED: YES El NOM FIXTURES 7 FLOOR-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB -----, .----f—_._._--._,_..{-------r___._.._.�__._._: i ..___.,_._,.___f- , (`_----.-• CROSS CONNECTION DEVICE { — — _.._{ _._ i DEDICATED SPECIAL WASTE SYSTEM i----- 1-- {__.__ ; _i ( i_ DEDICATED GASIOIL/SAND SYSTEM l i �`l t 1 ;if' ( __? - _ —_._ _ _. _ ._ k , DEDICATED GREASE SYSTEM i DEDICATED GRAY WATER SYSTEM rI.. % {_ ate.. .. .. DEDICATED WATER RECYCLE SYSTEM ; _..._ t. _..._ r.._. ...-_ .___-_i i DISHWASHER , .�_.._ ,-.y.. ...... DRINKING FOUNTAIN , FOOD DISPOSER ( __ , _.; r — . .{... FLOOR/AREA DRAIN f -, INTERCEPTOR(INTERIOR) t I-... _ 1_ _- { -) _, sr . .. _.__ ---.may..._. ---- i-- - _ KITCHEN SINK 1 i LAVATORY (.-- { ..._ __. ROOF DRAIN SHOWER STALL ( -7,I( -,ry..- SERVICE/MOP SINKw_._. TOILET URINAL ii ',1 - ; WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES I ! Li WATER PIPING 1..._. \I OTHER i t '.. 6\ Q { INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 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 i_:j BOND 1 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 171 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 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 corn lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L /-4 ,r PLUMBER'S NAME STEPHEN A.WINSLOW ;LICENSE#[12298 ] SIGNATURE MP( JP( CORPORATION Fl#13281C SiJ#1 1LLCFit COMPANY NAME E F WINSLOW ADDRESS!8 REARDON CIRCLE CITY}SOUTH YARMOUTH i STATE MA -, ZIP[02664 TEL 508 394 7778 I ii FAX 508 394 8256 CELL(�(� f EMAIL OUNTSPAYABLE EFWISNLOW COM ___. ,„x.,r_LLI Department of atccteents 4 ,)1!t_�' Office of Ioovesttgatdor-s-s _'f y 600 Washimgtosi,Stpeet Boston,MA 02117 • % •� 514vw s ssgov/die ' Workers'Compensation Insua'aanee Affidavit:tnilders/Costreactors/Electriielans/Plumbers Applicant Information n Please Print Legibly .- Name(Business/Organization/Individual):e.c.• ,5,A5{o� y(Vn��ptv,c� 4�l�Q.Qp,/ `,2)1,n0, Address: (44ositen C.,1 t✓ City/State/Zip: Phone#: `5OS-3dl9�117S 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 .employees(full and/or part-time).* have hired the sub-contractors 0 I am a sole proprietor or partner- listed on the attached sheet.t ?• ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working forme in any capacity, workers'comp.insurance. g• 0 Building addition [No workers'comp.insurance 5.0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions I.❑I am a homeowner doing all work . right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs insurance required.]I 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. :ontractop that cleric this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. km an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site 1 formation. tsurance Company Name: 1r1Yr(p+,J' C kJ O.jt , /)f wc& t CQ. \ e1t�Gt4✓ly oliey#or Self-ins.Lie d#: \8'AI Pr Expiration ` Expiration Date: I—I'" apt 7 rbSiteAddress:al GGMrhanw-2e--1'4h 1 Q) CFvz, J�^ 1' \ City/State/Zip: O,')LIid .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 f up to$250.00 a da a ainst the violator. Be advised t{{��t a copy of this statement may be forwarded to the Office of tvestigations theDlA for insurnie overage very tlron. do hereby cert�un a ee sins an penalties o pe jury that the information provided above is true and correct. igna �A"^ Date: d o11 3 I 1 RO) hone#: .S t$•3T-1-777% 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#: 1 MASSACI=3LISE T TS UNIFORM AIPPLICAT IOb\I FOR A PERMIT TO PERFORM GAS FITTING WORK nil • CITY _. �1� � `.! /.j:�/�. _ ' MA DATE �- d /� PERMIT# '-��`1� ' r y� .JOBSI I E ADDRESS: 2 # /jlvL' � t w� . . J OWNER'S NAME 6DGi r 1r/2.c ry OWNER ADDRESS ' TEL ^ A • TYPE OR OCCUPANCY TYPE COMMERCIAL` I EDUCATIONAL J RESIDENTIAL, PRINT CLEARLY NEW: , .. RENOVATION: :y...... REPLACEMENT: PLANS SUBMITTED: YES-...,,.1 NO' 1 APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 , ..._.._....... ... .. ............. • .._. �. .: • BOILER ! i' _ � . . .-_ _ _ ° w... : _ ` w_ F sF �...._ H .._ . BOOSTER = : ._.. :.. ... _ '._._.._�.� ._._.....I .._.. ..._.. .. ..._ _.�_ ...- .... }��w.. ....... _ - .... .441.14 CONVERSION BURNER ..�.�. . ..»�. COOK STOVE . _•.. .. . ,_.",,.•..r..v:s<: :.•.<....+,...w•.w:,•?.r,aaw.aw..: . "E <a.+vm-o... .w,.<..a.... ' f • DIRECT VENT HEATER ,` -- .-Y r�w�aw f l : i 1 w, �. a.a.aj? . ,r. DRYER _ . a ... ._ :.�.._..�,....�., :r,..w,a.�a.,: :n,.:.<.r.r.-wa:.�,�a.�,..� .._ <•� s,(�wr.,.wH FIREPLACE 1! i •. I .._.. ._... ....... . ._ �:.: ww� • :.�,w. ..n�•'�::<o-.tlr..+\:w}�www.Yaas,awi.:/.rlY..-a':c+Cm t�MroeeVwwsN•cJ•.ev.cws,nr:'A sL,_KH,.n.wr'n.r,>'Y'-.=•2 a A ...w".•F'.MWrw. FRYOLATOR : ; ° ," ' ` '`� " < aw.ww....,.,•-.-....s.a.awn :.. .... .1. own vz..ea,•••.<:wsisessnry:.w..:.w >.".i ,.......w .or+:.••••**-••••..l,mo1. "...m.� ........' a.........w w,w"we.. • FURNACE ? ? -._. . . r wra•.w.,,wwri •.ae.wr,.•.••�..J ' 3 ?�-...,w...-+ti v-s.,�.s.w,•�! n GENERATOR "s GRILLE : ,. . w_. . . �,.�w. w.. s ...... .. . _. �w. # .w INFRARED _.�. �,w . ,.. HEATER ,� �...r.�.<:_..; x�,,.�..�:....�,,:._..,...,_ ..-..�..,.a..... _ �n,a.. •, ..-.. :.�.. LABORATORY COCKS _. 1 �. ; MAKEUP AIR UNIT _..._,� . . 1 1 -._:__..... OVEN �._ POOL HEATER ` • i' ,. < i ROOM 1 SPACE HEATER i ...w w�, . �f,..,:......,, _ .. . . ... ::•,...,....... + w ..w a. ROOF TOP UNIT ... ` .. ..... t; r? _... •. : .. w �a.� _ • ` . H • . .. --'f; i _. ... .r t ' t ..£: '• Y .,.<«.."... �"ti TEST �; . ; ... . I. �. ,.,.w� - .., ;� • _.... • UNIT HEATER SS f ..._... ..__ __w.. . ........... �'n UNVENTED ROOM HEATER ` t: f - :I ` - WATER HEATER ' _ ' J w OTHER _ . • _.I: .-_....wM_._ . .1 __ ., . .. -.... ....fi } ){f ? i ...ri<•nr l iS n•1t ' i .--f ._._....._...__.,..;.._,....._...__-..._...-_,......._*x.-:::.:::r:::.,•:•r•:-rc:r,•»:r•nu_.—.._.�...__,..:•..�...s....... - .........a.."o .,..»..._,_".wi ......aw.,... . ___. .... _ _-_ .. j ... - .. _ .. .. .. .. .. .fit» f� .. ....j £ "' _ _ � . . ..... ... .... _ +_ J •_ww.. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES I!<I 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 a.. BOND U. :1 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 ;..V...,J' 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE # 12298 <x SIGN TURE t s MP .! MGF . JP JGFs j LPG! _..": CORPORATION # I LLC �# 3281C PARTNERSHIP .:,..:.`:# _Mw.__w . COMPANY NAME: E F WINSLOW PLUMBING & HEATING J ADDRESS • 8 REARDON CIRCLE CITY SOUTH YARMOUTH t STATE i MA ii ZIP t 02664 TEL • 508 394 7778 _ - , FAX. 508 394 8256J CELL: N/A .w !EMAIL' accountspayable@efwinslow.com „ ii2H' DG�r'.ellai eP Of MedP.#'�laiicCMG?E . iV i ?i! Office ofllrrav&t1igoeio s ""600 Wtshi aggor S 'eeg • r; Boy ors, 02111 • t 1www f/ asa gov/#J Workers'Compensation Insurance AffndNvit:Buillderrs/Contlr actorrsfEleet rnenate- ?lumbers AApincant on a do:n "s Please Pra>t�ft Legibl • Name(Business/Organization/Individual): E aC:•its 1 rk5 I qv.; OV„ t owes 4 q�.c�-, Qa , hrl( Address: Q ofauti CC(aP— J City/State/Zip: 'Soo-le‘ Yr-v-T.N.- mPc Phone#: S-391-1`7Ci . Are you an employer?Cheek the appropriate box: Type of project(required): ,41 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,t 7. ®Remodeling ship and have no employees These sub-contractors have 8. ®Demolition working for me in any capacity. workers'comp.insurance, 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0Electrical repairs or additions required.] officers have exercised their 1.❑ I amia 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.] 1ny 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:ar}d 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 iformation. tsurance Company Name: i' 'r Y();,.3 CA i-t10-)1 -i1,` t eA C .4`-i olicy#or Self-ins.Lie.#: \ I A Expiration Date: C—I — au-) )b Site Address:,)3 G3+Wv‘an a- )c S CCue3144• 131111 City/State/Zip: O„1 -1(cs 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 Cup to$250,00 a da a ainst the violator. Be advised t at a copy of this statement maybe forwarded to the Office of • westigations o the DIA for insurapeloverage veri caion. do hereby certify an e e ains an penalties o pe jury that the information provided above is true and correct. ignatu3 6r Date: (ot.) 3 l 1 ‘sel hone#: ,cl ..;qH P 7 778 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other . Contact Person: Phone#: