HomeMy WebLinkAboutBLDP&G-17-000627 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
+�n: ; CITY �.« 1-,N . JDdtLIrd MA DATE 2 c E V/ _`/ ,
:..Imo.y y i PERMff'�F i�+1 . 7
JOBSITE ADDRESS .• IX-12 tfrr mire XOii'i> 1 OWNER'S NAME et-ti S 1°.-z LgA/L
Ir OWNER ADDRESS r',92?c' I TEL " JFAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL D RESIDENTIALD
PRINT
CLEARLY NEW:El RENOVATION:L REPLACEMENT:D PLANS SUBMITTED: YES E NOD
FIXTURES 7 FLOOR--* BSM •1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1 .i( � .z (T^'h71711. ..ll ,, I `C-�r-,1 �--
� .171:
CROSS CONNECTION DEVICE I,__'I _._ T [ ,s,;; .a3[. IT # -(-31__ _((77r_71. . _:(„.___ [-`-
DEDICATED SPECIAL WASTE SYSTEM _ - il.-. . i----[ (7._:--,. I _ . ;I a� ,L_ • i1 'ram � _I
DEDICATED GAS/OIIJSAND SYSTEM Ir__ .. I_ Jr- ,i1`-;[- 1[ (� r r - ,I_ _ �1 _.'ri i
DEDICATED GREASE SYSTEM [-�ll I. 1F L -II,a:r.�r(m_,-- (..__.,--� ___ ,fl. _ :II.__ - ___-.li _._.._1—C—
DEDICATED GRAY WATER SYSTEM ( ". r r ..jr, [-._ ; ,-F (i( Ji(-- 11 1 �-{(+
iN DEDICATED WATER RECYCLE SYSTEM r..,i( r- (- 7-r:71 ,r-- _,_T[ 7[- i1 �I - 1.( $r—_
DISHWASHER I:. ,: I I : . ' 1,- f 1 °�- °. C-�` . si .. C
DRINKING FOUNTAIN r 1..,. 1� yC, , --.�1- i[a. Fr- 1.-._rI_—F.-7 __1r----F-[„__
FOOD DISPOSER 1,�.,. - [—iM 1 . 11 r 7- a^ 1_ (-11- 7 I� r__
FLOOR/AREA DRAIN [ILL-� ( {�41—�I lI _.:I :r. 'r 'i17'1 [7.--. r
INTERCEPTOR(INTERIOR) I__ �I ._1�_ -r�......._ 1. ;[,--II _ ,,(:_. 1 .. I. : • [1,:..._-a.4r- :`
KITCHEN SINK 1_ -�:) . _;I_ -'I . '.f_-71.-.7 1. ''1 " _''1 7-.--'-T -HTT .. . "`I -li
LAVATORY I 'T .iI_ `.(. _ II:.: �(--T :1_ 1—_ �`.( -__7.1
ROOF DRAIN [,�, _II r (- .1_... 11 L— 'flTh. ,I ir— I r -(
SHOWER STALL -.,a= 117._ I[ : -;__ vi.-_ (I s, a1—r-�,r 1 �_IL . 1 t'
SERVICE/MOP SINK I[lhi [:„IJ. y�.�i--''(. �;r-_i*:_ ' '
TOILET I �1[.... _ ._,.; . _- .IL :_ [I___ .;I_I1.. ._`r- ',`l '7 ..�1.. '_-. _r-
URINAL 1 [r (. [. [__ `-..,I[. x1 i 1.. ;r--E--1L! , L
WASHING MACHINE CONNECTION _.. .91--1 -_I .._„ -'11_ .. 11 11 'r `r---1 11 [__:_,.
WATER HEATER ALL TYPES L _'.I_ . _'[TJ .. ,ld�_,,._'rl. . i..__-HI- ..,L.�,T_:A .. . .1.. ___ IT .
WATER PIPING _l1 ---Jr - f- 71 1`-1[ r '(-J : ;'r^. 1 4- K1-
OTHER - --1-. —r I—__f 7I .--. F 1 I. .(—'r-,r1 ,[�
_.�w�_ ____s -
L ___,iif- --1__- ir__ II.`.r:._ .—i1-_ _:I [ 1—�-ter_ _ •
a:___ „r,y.—_- INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO D
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY E OTHER TYPE OF INDEMNITY® BOND D
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 0 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 tru 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 ance with all Pertinent of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /�
PLUMBER'S NAME STEPHEN A.WINSLOW ffi _=LICENSE# 12298 i SIGNATURE
MPD JP D CORPORATION D# 3281C I PARTNERSHIP 0`]#L , LLC0# _;
COMPANY NAME L F WINSLOW PLUMBING&HEATING i ADDRESS 8 REARDON CIRCLE - - --
i
-
CITY LSOUTH YARMOUTH _ I STATE= ZIP[Oa__ TEL 508-394-7778 _
FAX 508-39478256 CELL 1 NIA j EMAIL accountspayable@efwinslow.com _._ _„__ .___..,_-_
_w_=r Department of IndustrtatAcctaenes
t 1� / Office of Investigations
e='sNI= 5
�_.-,'i.`_ y 600 Washington Street
Boston,MA 02111
•�. www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information /� 1 Please Print Legibly
Name(Business/Organization/Individual):e.c•W, .510%I YLV�.bi✓tc( L 0<.0.t'✓ , c'e.)1el(
Address: S' Q oattn Gtf.(.Q- •
(J a
City/State/Zip: So+)k+'N /cr vNc,.�A-t-+ MPc Phone#: `SUli-394-1`'7
Are you an employer?Check the appropriate box: Type of project(required):
XI am a employer with -70 4.0 I am a general contractor and I 6. 0 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 7. 0 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 5.0 We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
1.❑I am.a homeowner doing all work rightof per MGL 11.0 Plumbing repairs or additions
exemption P
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.]
hay applicant that checks bok#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 subcontractors 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
formation. //�� -- (�
isurance Company Name: ArYO>.1 (�J a--)l ..�-1�J'CNCInCC \. elrvye°\"'1`1
olicy#or Self-ins.Lic.#: M$A( ik •
t Expiration Date: (—[- anl7
)1)Site Address: 3 r w•ea.-ii'h ,.h1 y CG' ' Ygkyk n1` City/State/Zip: O,)4 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 da a ' st the violator.Be advised t a copy of this statement maybe forwarded to the Office of
•
tvestigations the DIA for insurapee//loverage veri a on. I
do hereby certify un a airs an penalties o pe jury that the information provided above istrue and correct.
igna • r Date: (a)31 i aO[b'
hone irk .S[)R•35`4-.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#:
0 Pr(/'
. ,
,-- ,
-.1*. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
• !gal_ -- �1 - _s w_... .+.ter..1.M•.......w_..-r._
- _11_ CITY ._...::)1.-__'71..��L.n.1.?_m-- I_L"� MA DATE '- 2 - .,z C /( i PERMIT#
JOBSITE ADDRESS ,T-_p w e t T-,,t,i. OWNER'S NAME A iv Sr; ti ji)/6--
GOWNER ADDRESS S [ TE .. _ Y > FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ElRESIDENTIAL
PRINT 0
CLEARLY NEW:EI RENOVATION: DI REPLACEMENT: PLANS SUBMITTED: YESEj N0E
APPLIANCES 7. FLOORS-4 BSM 1 2 3 4 5 _ 6 7 8_ 9 10 11 12 13 14
BOILER I 11— . I. ._. ' i:_.. . 11_. �i li 4 . II. _. i! i..... .. i! -- t_ -
BOOSTER I____; --- ►I. . ._. . I_ Ir..-
1_. -..T. -nl. ..!1—. . II-. , . - . "I. .. _1 . ,I--. I L i.
CONVERSION BURNER � `..�`.� , . �..w•-~-l`' f ��.��,...� . , _ j��
t�Y( I. i C. . :.I -_l : --- ii- ( -- t 1._ . .I i _ . -_ I f ff I.��. `
COOK STOVE I L.__. I _� ;! �_'i._. . 6�. �i1- :11� {.I` �h _Ii--. � ':ilr�. _.
-,
DIRECT VENT HEATER I_ -- - -1 !--- __-.II 1: .f.r l . _ I '! r _ '+.I,-.. {I.. .-.. I-.. ... .. '!_ . _ If L1._..._ .-I 11.
/N DRYER - I- --.�� Ir.... =11_7..� _ 1.�__._tl:.__ , __,..E�__.._..a.�y I_, _ r---_. ;---- i-,._ ( -.-7_ 11 1--- ... 1
FIREPLACE I .1. . _ ;1. . I �� _ ' _ _."._ . _ _ih_. _ 1 1I . 11 'I.. '
FRYOLATOR ---- - _ - .._,, _�_ . --- _, _ _:` .Z.,
1 I. _ 1 I 11.. _a I. ?A. .. ..__ 1-. I_ I I 1_-7 E- 1_7- ,
FURNACE !_ _ � ____ _ ' I - - ' �_ �_'`{ _ i :. ' _ ,--� - - -�..�� .. . �-==-
i I ,I. _ 'I, _ .f' _ ',I_ _i_ ;I-_ f1 _11._ f{ _E{_,
O GENERATOR I -:�: . 1 .. .. I:__.. I__- ' �x+.-E: _ iI_ u ,I. 11 r - 1 'I.__ -: -+_..'1
rK GRILLE I I_ II. .' , . fI- . .I s1. .,I._._ j_ :,I
I- ''1 _ .,____. .II-. 1 x�
INFRARED HEATER Iy 1 . ' I.~ . ' 1. _. i_ . I-. �`i... . Imo..._ I.—. ' - 1- 'T. __ _I ... . '------1
..LABORATORY.LABORATORY COCKS +...�._... (�_.._.. ., 1__. ._.. 1. ,, ,;: : {,--_--�- ia �,I _ .,I----- I ,--�--=.xi- I y�{.. _ ..
MAKEUP AIR UNIT I_ .i___ I� -_. ' _. -- __._< _ J ;�'"�'''''^�
.l 1 (�_ I� 'L��_-- I I. �.� Y .... � I 1. _ 'a I�1,r. r 3'1�!..
OVEN f l 11_ .�f- - _,C I�. ._i1.�_:�; .�I�._�_1 i�.�_.;I _- _`1.� �I . I��I- - '� _
.POOL HEATER 1_,,,,..,_ I 11 . . _:I I.. . MI!_.. .1'. . . .i1 .__II �►..._ , ..fl_ ,_,I,....... 1 _ _d_ ', PI
ROOM ! SPACE HEATER I,�-}I—. . _TI _ ` ! -IL.
1-- `I__ - �1 I I 11 Y.t,lI , E !
ROOF TOP UNIT I,_._ 117 .� I. . i 1 I . .. . .i 11.. . . .I� _ I. i_ _`. .�1.. -- `I~ I I---- , iI I
ITEST I-. .._ I . .i_. - 'f-- 1---_—_!...._HI, :_ 'l,_ 11 __ �`1 1.... ,:. -:.^_.l r._ 11_ -
UNIT HEATER 1,,,,- 1. . I . . ':I. . .1- _ ,Sr_.... _ L_ 1�� . 177. II-. Q IS . _`I .� i-_ 1 ��L.
UNVENTED ROOM HEATER illy � I . ._':1,.._ _ ;(�.� 'i. .. . .. -3E _'i._ . __ I . _ ')_ [. II, .If, i I. - . . . T,._ _�
WATER HEATER I,__../ 1 11 . i 1= I . ---1,_..:+� . . I 1 . . )1. . ..l . ..ti . -
OTHER --_._ _..... ; 1~----_1l -- . ' I_ . . .li1 ''I .7 I '11= ,1 1. .. . �I.-� _ 1�, ;. _. .r _ _.-.y_I --- 1. . _ i
I._... ,_,,,,::...;=.....,..,....=.,,,.___:..„,77„....„..„....„.:=_,,,!
:. I .. .‘ -... i... .).1—...... _-7. 1:::::_cr_7172
1,17..___17::1—_,. .__:.:EL.L.:. :1- 11. .7.7.17„IT 1---",, I;„._.,j I—_ .. 2
i 1. I. i
-`, I . ..._ i t I _ . 11 _ :..1,. ..
1r.::�.f ,j,., rra rc rre ; ,-. - fn � -' --r. �....L;_._.,...! [+ ' r.„.,.. ,.„.4r : 7 �:„.„
• s
- • - -... •._..
INSURANCE COVERAGE
have a current liabili ► insurance policy .or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES El NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ETi OTHER TYPE INDEMNITY El 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 0 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 isz ued for this application will be in compllance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
• .
-' 'it K, 1/.,2. ,, .fi .....-
PLUMBER-GASFITTER NAME LEPHEN A. WINSLOW }I LICENSE #;12298 �' / SIGNATURE
MP El MGF D JP Ij JGF rj LPG! 0 CORPORATION #LicJ PARTNERSHIP 0# ; LLC # J]
- � -.rI"'.'..�'-J
COMPANY NAME: E.WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE
� - -y,...raronacxxcea s�oissaaoo�ca-�-� -:�r-vc m���--"--
1
CITY SOUTH YAFMOUTH STATE MA�_ ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 Aii CELL N1A ;;EMAIL accounts able a�efwinslow.com
___ Department oj'lndastrtal Accaaents
l =r11== /
=k . Office of Investigations
e=+Ini=y 600 Washington Street •—
1l11= Boston,MA 02111
�-...7",.- www.mass.gov/dia • ,
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information t� Please Print Legibly
Name(Business/Organization/Individual):E.C•VIIn5iOyu �[V�triivAct 4 af.01'1 Ce.}1'/1t•
Address: g ( Pntv) ar .2-
City/State/Zip: Soo k+\ `{orr^^cw.,.14n NA- Phone#: `fib-? I-1 Ti C1
Are you an employer?Check the appropriate box: Type of project(required):
XIam 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. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
I.❑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
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
hay applicant that checks box NI 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.
lm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site r `,)ormdtion. /n1 �'(Y ..s
tsuranceCompanyName: (� D• C ) nJo 1 ,it -i't1'st'"Co ap"ecvvy
olicy#or Self-ins.Lic.#: 1 S A I Pr •
i Expiration Date: (-1` anti
tb Site Address: Lc+,3 w co, vreo•-(l"h Ad-el CG`Q�'R'V�1- P`l City/State/Zip: O,)w 107
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
nilure 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 may be forwarded to the Office of
•
ivestigations the DIA for insure overage yeti a on. r
do hereby certify uns an penalties o pe jury that the information provided above is true and correct.
ignat&: r Date: t�)3 1 I aOIt b"
hone#: .Shy-' l`[,777d
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#: