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HomeMy WebLinkAboutBLDP&G-19-001035 dF\e' Cam, .. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ���— ii PERMIT# -Co / b mt1=F CITY 1` J`Q. !? --- ,"u.l&v-..1. _.._.._I MA DATE I.�,:1._I a-Je..; /r'iP/9' /�O `J� JOBSITE ADDRESS S6_._ w -f { OWNER'S NAME[// L a- I P OWNER ADDRESS ,.6-_3..Ygu. g�._„7,---„,c�_�l�y„✓ _.. Al _../ )j TELL y P Z FAX ' ,zzo� TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL [1 RESIDENTIAL PRINT CLEARLY NEW:h._H RENOVATION:, REPLACEMENT:gl PLANS SUBMITTED: YES I NO 1-11 FIXTURES Z FLOOR--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I { CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM - -I i I ' DEDICATED GAS/OIL/SAND SYSTEM I ^( ` 1 ' DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM i I I 1 DEDICATED WATER RECYCLE SYSTEM i DISHWASHER I. I I_ DRINKING FOUNTAIN _.._..•.__ ; FOOD DISPOSER 1 I�J FLOOR 1 AREA DRAIN INTERCEPTOR(INTERIOR) I KITCHEN SINK 1 1 LAVATORY ROOF DRAIN SHOWER STALL , I ; SERVICE/MOP SINK 1...___ TOILET 1 I_:._ URINAL 1 WASHING MACHINE CONNECTION I 1 .I I 1 WATER HEATER ALL TYPES i WATER PIPING i 1 OTHER 1 1 V I i " INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[J NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I v` OTHER TYPE OF INDEMNITY i BOND 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. CHECK ONE ONLY: OWNER IT AGENT I-I SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tr 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 lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (2-11-44c-S6'—, PLUMBER'S NAME L STEPHEN A WINSLOW LICENSE#112298 SIGNAE MP] JP I, I CORPORATION#�3281C.._..,-._JPARTNERSHIPI� # _. jLLC #I! , COMPANY NAME E F WINSLOW .ADDRESS 18 REARDON CIRCLE } CITY!SOUTH YARMOUTH _:—u_^_J STATE j:,,,. MA_i ZIP 02664 I TEL 1 508 394 7778 �1 FAX I 508 394 8256 I CELL E EMAIL �ACCOUNTSPAYABLE@EFWISNLOW COM_ _a ;_ s A; 4 r ^x .,,,,,,____I IJ 1 6,,i. Dep r/me,sg 0f1 1ILa®?8g'tr<brUli,C,excie m t"" Office of Iievestigeggions 600 Wasiak-aeon SPeed Bosgoi,lug 02117 4:` Www es gov/ i • Workers'Corn peysati sit 1.11sttl(lra?�tinc Affidavit:1B> tiers/Conttrraettorrs/Eleetrfielans/Pilambers pDlaearat Information Please Print Legibly .• Name(13usinesslOrganization/Individual): E W iA$(@ j QtV 6 tv 2 ���� c„_f loll Address: (60icvt City/State/Zip: •Sops Yortr-ic," , MF Phone#: '50S-3c14 -1'7?� 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 I ,employees(full and/or part-time).* have hired the sub-contractors 6 El Now construction :.❑ I am a sole proprietor or partner- listed on the attached sheet.3 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 required.] officers have exercised their 10.0 Electrical repairs or additions 1.El 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.❑Roof repairs , : insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] thy 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 sub-coniractera:and their workers'comp.policy information. lin an employer that is providing workers'compensation insurance for triy employees. Below is the policy and job site rormation. 4 ' tsurance Company Name:}PY Yl):�} ' r��t'tltz�i ,purer't CCU Ce v."✓ty olicy#or Self-ins,Lie.#: \ B I A. Expiration Date: k--1 apt-) )b Site Address:, 3 C W cY 1 w•E'a-00h ,0J Ctr\e tl \\ City/State/Zip: (:),)4 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 der against the violator. Be advised that a copy of this statement maybe forwarded to the Office of westigations I the DIA for insuanye”overage veri)Kajion. do hereby cert)ran e e sins an%penalties o pe jury that the information provided above is true and correct. CC afu ' r Date: Q ot_ 3( an ( hone#: .S 1• `A'• 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#: MASSACHUSE T TS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WWVOIRK [ 5e '- : 3, % � ,� � .iMA DATE / ,FERMII n � .. . SSti JOBSITE ADDRESS.6 o.o9 , f�,v .??L,1/,,-}OWNER'S NAME .6yecp C,c _11/ ///0.!0., ,_1- GOWNER ADDRESS 4,1 Y_etY,. , l`f_- cc-_ 4,e,frp___24/f TEL?d� Y / ..QJ FAX, �_Y e, 3 �PRIEIli�R OCCUPANCY TYPE COMMERCIAL•_•__f EDUCATIONAL j RESIDENTIAL CLEARLY NEW:°,,.„�. RENOVATION:'...,. REPLACEMENT: )4 PLANS SUBMITTED: YES LI NOU APPLIANCES 1. FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I E. ;,. - BOOSTER ; _. n__.-I' __-3'.__.._-. i 1` - 1.... ... `_--f .... CONVERSION BURNER COOK STOVE 1 k i '- l - I_,w--.-1 ... I 1'_____.i .�... _i .. . DIRECT VENT HEATER J, I 1 J. ji •� m 1: j_m> ,M DRYER ;. I:� ..,. 1 I 1; I,., .I 1 I FIREPLACE L.-----I ._. .., ...:1 I_..__ 1 .I „1 FRYOLATOR 1,,,, ._.a.,.., , s' E 11__I I .. I t ' FURNACE J t; l _Ii ; GENERATOR . k GRILLE _....._... ! 1`,.. J�_f'. I __ 11 1 t. INFRARED HEATER 1 ....._.l J!.___ I._,—_1 1 I I —i _ _; I 1i LABORATORY COCKS I - - _MAKEUP AIR UNIT T _ ,I• k` 1 i 1 I I 1 t I — OVEN . �. —I I •.-_a.__.,;_ If _I. ! .I 1• ... i - POOL HEATER I i 1 i 1 k I;..: `i I - .._�—_.. ' • ROOM/SPACE HEATER i I•—, I I• -��11---- t :. . .I J._ .._ .I I;__J,. ..�I ROOF TOP UNIT I I _ I ... �-- —._. . . :. i TEST 1-s--i'• i i..._,.-_ --•--1 -=`'=I_.. T.-.I . --I • -- UNIT HEATER . k._ __, . .F fE I'_ 1 k I_,...- 1.M...^I I. UNVENTED ROOM HEATER 1: I' i s 1' I _ I I ...._.__.1 I —. I • I '•--•---' _ WATER HEATER.._ ...... _..__.. ._._ . . -J i ...;: ... r...1. -I — -- _I I. _.. f ... -- ... _ _I " OTHER.'_.._...._._ ._. .._.._ ..._ ._ . . _.!: I I` . : !' I` _ `_ .. . _... • I E T. j f' I: I I____a i',..._.-_ - •_. i'_____ i ___. i'---PH1.... __I._ 11. I._..__..._.1.,_. 1.. : •-._..-__::1.. --_____ N.INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L.d NO U t I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY -,+,J OTHER TYPE INDEMNITY ,I BOND ID 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 ;._.,I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are tru 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 comp) 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 SIGNA RE MP...;J MGF. ,. JP U JGF:Lj LPG! JI CORPORATION•U# 3281C 7 1 PARTNERSHIP �H:# I LLC .,J#. - I COMPANY NAME: E F WINSLOW PLUMBING&HEATING ADDRESS:8 REARDON CIRCLE I CITY SOUTH YARMOUTH 1c STATE i MA t ZIP i 02664 TEL'508 394 7778 FAX'508 394 8256 'CELL N/A IEMAIL accountspayable e.fwinslow.com Deparimeng of lrrU I P.rrgeg!lmega o' - i� Office oflvves gfgior �r ¢ w 600 tr tI ig€rngreeg ` .� ;l G Bosgg vs, 02111 ., WWio mes gov/dfe ' Workers'Cox;pensattiomt Insurance • tll rdavit:I uilldlnra/CConttr ©tn g/Elfflfrri©n:ans ,,,19 till bens A,''licant information Please Pint Legibly .• Name(Business/Organization/Individual): E,c• ins Iow ` kt 6 q� �ee,...\-,'- G. I elt Address: (pouf C)rc � I J City/State/Zip: 'ors•I'N Yr cs„ i-Of Phone#: ¶1i-3T-i-1'ie . 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. El 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. [Ti 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 MOL 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' 13.11 Other comp.insurance required.] #ny 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 rormation. isurance Company Name: .,,i (`kJ Irti oJ► ,..T—dl f(),(ty.e1 CmyNekil olicy#or Self-ins.Lic.#: V3. .I A • Expiration Date: c,—1 - aO1`) it)Site Address:,)3 Cnnr,,arl,e OJ 4 h AAs I C 4 J III City/State/Zip: 6,) 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 insurarpet�roverage veri Caon, r do hereby certifi,un e e ains an penalties o pe jury that the information provided above is true and correct. ignatu3 • ("4/ADate: (DA 3 l 1 aO[ '' hone#: . • H- 7 27 g 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#: