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HomeMy WebLinkAboutBLDP&G-20-000092 , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1 __ PERMIT#'�� a2�-ODBO 4,1 ';V.. CITYI__,� ---I MA DATE 7R / JOBSITE ADDRESS 125 1321'I►-XAti e_t Ailifteitzugl,OWNER'S NAME ayiTummnium � ��� • ' , FAX P - OWNER ADDRESS I� E ___..—____-._.._______�.�__�___._ TEL __ TYPE OR OCCUPANCY TYPE COMMERCIAL rji EDUCATIONAL 0 RESIDENTIAL0 PRINT PLANS SUBMITTED: YES NOD CLEARLY NEW:® RENOVATION:0 REPLACEMENT:El FIXTURES 1 FLOOR-► EMI 2 3 4 5 3 r' is 9 10 MI-�--- --iim 2 101101 BATHTUB �®® __ '.,���,��,, O pm mit CROSS CONNECTION DEVICE OK®um um T DEDICATED SPECIAL WASTE SYSTEM ®�®��® i mil� �®i®OINIMIN N,®,�®. it DEDICATED GASIOIUSAND SYSTEM ����I� �IIINFillrall:WIN � � ®.� DEDICATED GREASE SYSTEM �� DEDICATED GRAY WATER SYSTEM 01111®MIN®®�___I_INIII,N®®1W __ FIMTIIIIIIIIINWI DEDICATED WATER RECYCLE SYSTEM IIIIii iiii ilili®MM.ME iiiii'®INSIM NE Mil r NITIIIIIIIII DISHWASHER .-- Tig. ®�� �®�®,®® DRINKING FOUNTAIN �_i�'����'�'�uill I FOOD DISPOSER �il®''® ®�:®`�® illi O FLOOP.I AREA DRAIN �I 1®�MO MM ®®_�=,� Ns KITCHEN SINK INTERIOR) ®M.®®®��'�,®® LAVATORY ®, -__- - - _W®MN®®®®r� r®®MN ROOF DRAIN M ®®�®,®®�®, W SHOWER STALL _ _ _ _ SERVICE/MOP SINK : ®�� I ! rA�ll_�WWI TOILET ® 1_�— �(� ini URINAL 0 ®�:� -- -- WASHING MACHINE CONNECTION W _ ��® ®ice�i WATER HEATER ALLTYP W_ ®�®�® 0 _ O WATER PIPING Imo,_ _ I11 OMr®��W�� i NWI OTHER — II Mli N�:®im ®MI=® 1^ v J INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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. AGENT CHECK ONE ONLY: OWNER SIGNATURE OF OWNER OR AGENT are e and accurate to the best of my knowledge I hereby certify that all of the details and information I have submitted or entered regarding this application and that all plumbing work and installations performed under the permit issued for this application will be in c.p.liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / .4.:-. _ -�_ PLUMBER'S NAME'STEPHEN A.WINSLOW gv_ {��j LICENSE# 12298 SIGNATURE MPO JP® CORPORATION El- 3281C PARTNERSHIP#��LLCD#I==:1 COMPANY NAMEI EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITYI SOUTH YARMOUTH 'STATE MA ZIP 02664 TEL 508-394-7778_-_ --. FAX{508-394-82561 CELLI NIA I EMAIL accounts•a able•efwinslow.com _ � H 14v The Commonwealth of Massachusetts ` - ' 1 Department of Industrial Accidents l., ' 1• " 1 Congress Street, Suite 100 4V�' Boston,MA 02114-2017 0, Imo" ° www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):E.F. WINSLOW PLUMBING & HEATING CO., INC Address:8 REARDON CIRCLE 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 88 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 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. tContractors 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.#:1909A Expiration Date:01/01/2020 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 MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and a pai s nd pen !ties of perjury that the information provided above is true and correct. 6 Si nature: ha,— Date: Phone#:508-394-7778 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 WORKWA.-37.1110 �� MA D 1PERMIT#! O �ok4=. CITY aeIr . _..... .--- ---.I ATEI-Z-J2._JIq. .._ . JOBSITE ADDRESS'25_?vault.* .-..-!AJ.\I_4W N'WNERSNAMELRA,101 ,tAee_ .__- .--_..._. GOWNER ADDRESS iS..A ....._-----.-•- .. ._..._._.-------------'--- TE41_11'31q:7. 1A TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL 0 RESIDENTIALEr PRINT CLEARI'Y NEW:0 RENOVATION:0 REPLACEMENT:Le' PLANS SUBMITTED: YES0 NOD APPLIANCES 7 FLOORS-F BSM 1 2 I 3 4 5 I 6 7 8 9 10 I 11 12 I 13 14 BOILER 7---__ _II--:-_II_ •II.. .._ 11 .. ..i1 .11____J_ ._.._:L--_- it------:1 BOOSTER I- IL1.. _ -I .. __-.i1--_If_—i1-^Ir�11 III : .__._ ....___1__ -- CONVERSiON BURNER L,_=_;iI_.. . I_..._._:�I—II__ -.JL......__II . . -.II.. .__.If..-__.iL. JL-I IL_.....I -__.._If-II- I COOK STOVE I- ___' -lI_.._._il_1._T—..-1 --=I--._.._IL. --.1 1�-'I � I-- DIRECT VENT HEATER L 1[7.7_1__i. ..._1. . ...it li......_.IL_iI--...-_II-.---Il......_.._II-_...._.(._.__..I II-- �11 DRYER _ -JI --.:._.: ... IL.-�__Il. ._..II_JL ...._I :J1...._.._II`.._.._1(- .:._,. FIREPLACE L.----'...---I L11. ..... •.-I� ,h I........_11..._.. ._.. 1�M� NE ® --- FRYOLATOR - , .. .:I)...._--I .1. .- .11.._ --I ......11.. _.:II......__IMIN®®IMM FURNACE 1 l�f it 11-1___-_I__._1 . I__ .fl .-1�1_._.:-1 _,_Ii �I ,_...._._.: _.... .,,..._. . ._ __I _ _ , ll.® j. 777 —'IF•- C GENERATOR. .... ____I Y _.... ._...__ L...... _ . _ _GRILLE .......`I-._ ..3 .. . .... INFRARED HEATER in-I I-- ._ II___ I—_IL=__IL----IT.---.-II_-._._II_._. _iL__JI—J1.._.._...:ICI—. LABORATORY COCKS 7 - -- -.I®1 --•-�------_ - _ :I_.. ...II . IL_ ...Il :IL- .. . .,(-I MAKEUP AIR UNIT L.- _.1 .:.----_L_,_L...._I..__......1--1I 11 ......II ...._._:IL-_.__II=--=�- •h-1 OVEN ®L__JI .^:1__IL..._.'1L..- I__:-_11.---...I .-.. .I ._..IL__.1 . .. : .. 1OL_,_J POOL HEATER -I _ I _ .L. — --11-._II.... .li®vim.... - ROOM I SPACE HEATER L_JL J_ ..'11-i1.__.._ L-_ 1l JAI.... I=1_____:{ -- ---•----RooFTOP-trron`------- �— _ TEST . I_.. .1�-1��. -- .... . _... 1 .. ...11 ,11 . .I _ i_. .. . 1 _ tQl UNIT HEATER �-711_ 1 - I... ._. ._ .. I i UNVENTED ROOM HEATER __. .=:1®f -. ..-'ll.......;I=11-I _ _1. _ .l_....•.. L:-11.__ ._.Ir_ I - - -1 WATER EATER H-.-.,_____„, OTHER 'I L._�1... .._'IL J1..._.._..I ii.. . - -.�-'il. =!I.--_. Jii 1f-11—_JL- L___JL .11__....ILL_:____I(—_L-C-1 ! .....41_ 1, -.._1,1_.-_.._IL.._II.._ .l . ....11_._...._.,II__....:1...__11—Jl._.._...:If=JE- :I=�_-._-.jlC_ _11 (1) — ..__� I ..... :ILL_ L_.._ --- — 1 y.•... ._..__. INSURANCE COVERAGE I have a current iiabilit insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _+' OTHER TYPE 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® AGENT 0 . 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■ .ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compllan' th all Pertinent provision :Massachusetts State Plumbing Code and Chapter 142 of the General Laws, PLUMBER GASFITTER NAME STEPHEN A.WINSLOW. •,-. ..._•_ , 1 LICENSE#.12298. SIGNATURE MP El MGF© JP 0 JGF 13 LPGI 0 CORPORATION[]#1 3281 C__- - 'PARTNERSHIPD#=]LLC OE= COMPANY NAME:(EF W . I ADDRESS'8 REARDON CIRCLE INSLOW PLUMBING&HEATING . --•-• •-- - CITY I SOUTH YA.RMOUTH, . .. ,. ____ _y_i STATE MA. 'ZIP)02664_ jTEL 1508-394-7778 1 FAX 508-3925 6 CELLI NiA , .., .• 1EMAILI accountspayable@efwinslow.com _ .. .. I qU The Commonwealth of Massachusetts - —. d Department of Industrial Accidents �VN� 1 Congress Street, Suite 100 b r` Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):E.F. WINSLOW PLUMBING & HEATING CO., INC Address:8 REARDON CIRCLE 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 88 employees(full and/or part-time).* 7. El New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. [] Remodeling 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.# 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 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. tContractors 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.#:1909A 01/01/2020 Expiration Date: 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 MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and e pai s nd pen lties of perjury that the information provided above is true and correct. Signature: Date: Phone#:508-394-7778 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#: