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Home My WebLink AboutBLDP&G-17-005413 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I W: � a4 CITY .... , I MA DATE , - Z...j PERMIT# 1ICI'C50/ _: .3 JOBSITE ADDRESS Z! art T�y ;1 OWNER'S NAME ': -. , OWNER ADDRESS ,. ,.:< ,..:�.., ,� . , ,,,.:.-��.,s. ,'', . .. I TELSG�t� Q�rFAX ,,.... .,o i TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL El RESIDENTIAL 14 PRINT -1 PLANS SUBMITTED: YES NOad] CLEARLY NEW: .i RENOVATION:I..,,e, REPLACEMENT:El FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE (-- DEDICATED SPECIAL WASTE SYSTEM I f I L- ; DEDICATED GAS101LISAND SYSTEM , _ = DEDICATED GREASE SYSTEM _ I _, Mir r DEDICATED GRAY WATER SYSTEM I,,,,; I * I I I, I 1 �I I� DEDICATED WATER RECYCLE SYSTEM ;,, 1. I [ __ DISHWASHER 1 t DRINKING FOUNTAIN -__LliiiMMini- - I FOOD DISPOSER IllitilitilliiMillilliiiiiiillililit -Mil- i FLOOR 1 AREA DRAIN r INTERCEPTOR(INTERIOR) I IMi I' NIIIIIIIMININIIMUN KITCHEN SINK LAVATORY naingung ---or---1--4--imu;iim ___ ROOF DRAIN I I r- SHOWER STALL ISH 1- R-I ' — I__-- � SERVICE/MOP SINK i - 1-------ir 1--- _ TOILETM�� 1.111,1111111111111111 URINAL IMINUN ��' -- IF L-,__ .ra WASHING MACHINE CONNECTION 'I. l_ I II I 1na S WATER HEATER ALL TYPES I { I Irinsann ::_ ( ^ I ( . I - 1 I it 1 ' .: r 1 ) v ) WATER PIPING ! - OTHER ( i 21 I { I, I r I " r w v� a r ,I { I I` r - I -1I --If" --r- '1 "' '` INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ed NO ID IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L I OTHER TYPE OF INDEMNITY L, I 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 E AGENT 1 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 a d 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 complia e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,, �' ,cam PLUMBER'S NAME'ST N A EPHE WINSLOW _,_ ,.- --1 LICENSE# 12298 ,... 1 SIG T RE MP El JPL CORPORATION( # 3281C PARTNERSHIP #- v. LLC # COMPANY NAME LE F,WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE W CITY SOUTH YARMOUTH ,w. STATE MA ZIP 02664 TEL 508 394 7778 1 EMAIL accounts a able efwlnslow.com FAX[508 394 8256 CELL NIA ,.y , . ROM ) 'T)ra y^�r e. ..ei e'? ` I a&f,'6,tA,c `�,1. -=: . J Oar :� Y lestip n., J �iia Al* fl ''ny gtois 'ei'e` ec J&seou� 02111 • ar„ x WwW✓ma s gov/day • Workers' Co1,:pensatloita il,IIsurestnce I4;davit: i:uilders/Contractors/Eleetridans/Pluinbers et.ppi cant Information Please Print Le ably .• game(Business/Organization/Individual): E.C.It/ii9,,,g ry I Q,, `�(, LA Q q t,,v,,, y�� l,�c o Address: % Q e 'c& l C .Q... City/State/Zip: 'Sou vi Yr• cs..t—ln C-1Pc Phone#: c5OS-3ct`fi-117 t.re you an employer?Check the appropriate box: Type of project(required): AI am a employer with 70 4. El I am a general contractor and I •employees(full and/or part-time).* have hired the sub-contractors 6. ®New construction ❑ I am a sole proprietor or partner- listed on the attached sheet.# 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 10.0 Electrical repairs or additions .❑ I am•a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions • myself.[No workers'comp. e. 152,§1(4),and we have no 12.❑Roof repairs • insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] 1ny applicant that checks box#I 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. :oontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. Jim an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site i formation. `` n ltsurance Company Name: , s (`•,. Av kJ o f Ism ex Cr_ \ ✓1i olicy#or Self-ins,Lie.#: \$A I Expiration Date: t H — apt') )b Site Address:,D3 Gnnrtia✓1 w-E'a-1 lh Ai-4,, C 23•\1j4 11)" 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 ainst the violator. Be advised t at a copy of this statement may be forwarded to the Office of • tvestigations the DIA for insurape overage ver i at on. I do hereby certify un e e airs an penalties o pe jury that the information provided above is true and correct. ignatu • r Date: ( 3 I 1 Rb l hone#: ,cy,•;14 P 777g 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#: , d a" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,t n�� 1,1=4 CITY .. . . . . .. ./ ._... . .. .. . ....,..I MA DATE...7 -/e-/7 t PERMIT# / .1.7P17-Od,�z/�i 7-_—.„ s JOBSITE ADDRESS ?/ 44-./jt )Z?,er ee i OWNERS NAME a e C 8 .......... . OWNER ADDRESS ' •TEL 5O YJeeZsmi FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL ; I- RESIDENTIAL CLEARLY NEW: _J RENOVATION: -._i REPLACEMENT: PLANS SUBMITTED: YES_... NO._ APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i_ -_? l._� _. .... I.... ... _ _. ___ i I I____J' ` BOOSTER .._...-..: j; I_ _i ___-.1;,..�.-_.. _ 1._._. _I j J I _CONVERSION BURNER 1 ._.. . . ... 1 ._ COOK STOVE I __J ! i __..-..__1 1 DIRECT VENT HEATER 1 , _ _I; 1.��.._( i_____ , J . __I, ... ..1•__`. _ DRYER ,,;, t: J __I J ,.j R _, _ 1 . FIREPLACE ..... . 1 € s _I . m FRYOLATOR _,__I_____,.f 1 I I �J .._.t ...... - _.... I„*x FURNACE � I : ._.._, _._J i I ... „i ..-..._.,,1 . I...�.,J GENERATOR - i € i ; , GRILLE : _ w i J I• I _._.;; .. 1 ,....___J .„,_:i I_ E INFRARED HEATER I_ _ 1 I. t 1 LABORATORY COCKS __I.... P J_ _. 1 ..._ . MAKEUP AIR UNIT J � l , OVEN J , I I J I POOL HEATER s i : I I €_ 1-..._ ROOM I SPACE HEATER _� I I I ___i , ROOF TOP UNIT _ i'' I . I ; .__ I i____ i.. 1' 1 . .......` i. I TEST 1 , ' I _. ,_ __I ! a —_.€ • UNIT HEATER t, I _ _ { I I I__..._._„I. . ,. .. UNVENTED ROOM HEATER : , I , ___ I: -i I ___ ___` WATER HEATER I a_.. I • ,,.__._ .1 _..,. I•,•....__.J; I____J__.._ .1 I i'_.___! .._,.__ " OTHER I I I I ,..J I . _._ i-.I 1 l I __J I .__i i li [. 1 1 1 _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ...I OTHER TYPE INDEMNITY 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 AGENT _.' SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true a d 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 complia e 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 SIGNATURE MP !, MGF:..... JP -.I JGF:_,vj LPG! _, CORPORATION r+g# 3281C_ PARTNERSHIP # LLC # COMPANY NAME E F WINSLOW PLUMBING&HEATING #ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA I'ZIP 02664 TEL 508 394 7778 FAX 508 394 8256 I CELL N/A I EMAIL accountspayable.,efwinslow.com Department oflndustrtal Alcciaenrs ro — 1E`! Office of Investigations ali ? 600 Washington Street �i " B��o�sfft�on,,M40�2f1�11 - ,(4.`...,,, , IVII I►'.mass.go ilia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information c 4 J Please Print Legibly • Name(Business/Organization/Individual): t.,c•W 1 sS 1 Ow Q(1 on6 tune+ 4 t.oL� Q� I el(. Address: (4 d� ,(aq__ . (�_ City/State/Zip: Soo Seh fc`r v-,cs•A i`{ik Phone#: 50S-V19-111 si Are you an employer?Check the appropriate box: Type of project(required): ,,IVI 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 !.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. ❑ We are a corporation and its 10.0Electrical repairs or additions required.] officers have exercised their i.❑ I an is 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 12.0 Roof repairs . . insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] \.ny 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. :oontractors 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 rormation. tsurance Company Name: PiY Yt) CA,-.)k r-k et 2_ ` kyv`) olicy#or Self-ins.Lic.#: Visa) A' • Expiration Date: k--t — ann )b Site Address:, 3 Cnnr`ai1 Vi'e J Ad e 3\11"' 11 City/State/Zip: C),)14 Id)? .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 Fup 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 tvestigations 8 the DIA for insuratpe- ,overage veri a on. i do hereby certify un,• e ains an;penalties o jury that the information provided above is true and correct. i, a , _ f1 �_ Date: (a it, 1 a01 stone#: .S1 •35M. 7 77g 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#: