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Home My WebLink AboutBLDP&G-19-005976 C"t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORE MA DATE�_Lj/11I17___I PERMIT# P /� i'`7-ov 7 �� a=��.. CITY 1�� Ymr+r� l �f1 -� - JOBSITE ADDRESS ! OWNER'S NAME / TELL Q'-.,'q._..l5?. FAX __=z-�.I P OWNER ADDRESS I( _�y r�n,nQ �nl�A�. Ii3L�].l-L� 701 TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL D RESIDENTIAL EL/ PRINT PLANS SUBMITTED: YES 0 NO[ CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: FIXTURES Z FLOOR--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB MN MIX1111M11111111 L_ A-__ spros,( __1 MI ,- CROSS CONNECTION DEVICE i.- A DEDICATED SPECIAL WASTE SYSTEM !—gm ;- 11 �_, -_ DEDICATED GAS/OILISAND SYSTEM �i� k ..__ ,_-i 1'--- `- —`"- 6p DEDICATED GREASE SYSTEM - �--..® _ DEDICATED GRAY WATER SYSTEM 9 r ^ Cr- DEDICATED WATER RECYCLE SYSTEM WE MN I I - 3 DISHWASHER _ DRINKING FOUNTAIN I— ` --CO _FOOD DISPOSER -J I� ., E ` - r--L-- - `V -: _ , - FLOOR!AREA DRAIN �� ____ r-- • INTERCEPTOR INTERIOR) I. _. — :_� I NW --_ KITCHEN SINK -- � ®�-� LAVATORY _ �� _ -._ -- N SHOWER ROOF ISTALL - — — I �� - SERVICE I MOP SINK iWl . _ MOM TOILET URINAL '� ,®M� �— —. ®1 �1.1-DW I - = WATER HEATEREIAE CONNECTION AM � �� WATER ALL TYPES WATER PIPING �MIl. _ —jMMM OTHER -�--, i-;-�-1 MIMI iir ----:-HNIN:1114,11111 iiirMilllaillIMIlli- - llelailii : , - _ _MIL_ ;11_1111r11F; ___I( MI INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of I. GL Ch.142. YES 0 NO C1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF 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 i Massachusetts General Laws,and that my signature on this permit application waives this requirement. 0" CHECK ONE ONLY: OWNER 0 AGENT __ SIGNATURE OF OWNER OR AGENThe Q I hereby certify that all of the details and information I have submitted or entered regarding this application are true anwith all accurate totthe best o s on knowledge wledge and that all plumbing work and installations performed under the permit issued for this application will be Inc pliance he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I STEPHEN A.WINSLOW __'LICENSE# 12298 - — IGNATURE MPD JPD CORPORATION 0#)3281C __IPARTNERSHIPD#M111 LLCO#_ COMPANY NAMEI EF WINSLOW PLUMBING&HEATING -I ADDRESS 8 REARDON CIRCLE _ __-- -----------. CITY`SOUTH YARMOUTH j STATE I _MA _ ZIP 02664 TEL 508-394-7778 FAX 182E221 CELL[NIAEMAIL account ef owc s a able wlnslom __ _ _ -- ._-— P Y @_ __ --- - - , Nk d➢66. GiQy➢➢b➢p bp/➢b b yyybb➢6 p/b ��.,'_ tr.66fDiD LCL➢b➢4.➢ybbiD r 1 _= Department®f Industrial Accidents � 1= ° Office of investigations .0,.ntei�r • 600 Washington Street s =qlf' Boston, sVIF`O°c �s' ,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit Bua de s/Contractors/Electri i licant Information caans/Plumbers e Please Print Le ibl me(Business/Organization/Individual): L. r.` ) i IN irksiovo ��,, ff i er�ct� ��• lei(. dress: ( . y/State/Zip: co ileN (°co-KJ-in MN Phone#: S- qy 71?� you an employer?Check the appropriate box: I am a employer with "70 employees(full and/or part-time).* 4. I am a general contractor and I Type of project(required): have hired the sub contractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached sheet.t ship and have no employees 7• [Remodeling working for me in anycapacity. These sub-contractors have p h'. workers' comp. i 8. ❑Demolition [No workers'comp.insurance 5. o insurance. p [ We are a corporation and its 9. ❑Building addition required.] officers have exercised their10.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing l repairs or additionsectrical repairs or ns myselmyself.[No workers'comp. C. 152 fce required.]workers' r 7 152, §1(4),and we have no 12.0 Roof repairs employees. [No workers' comp.insurance required.] 13 ❑Other plicant that checks bo.x#1 must also fill out the section below showing their workers'compensation policy information. ,wners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information z employer that is providing workers'compensation insurance for my employees. Below is the policyand'o ztion. ce Company Name: �� b site v s (` t/ yfuvrA n 1 or Self-ins.Lic.#: 1 S a! A Expiration Date: k I— , _ Address: 3r1nr+�c ‘r.'�c_ $� titi`� — C(^v , 61.i� a copy of the workers'compensation policy declaration page City/State/Zip: Q�y{� to secure coverage as required under Section 25A of MGL P 52(Showing lead toht e policy number and expiration date). o$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK $250.00 a day against the violator. Be advised teat a copyhe imposition of criminal penalties of a ations • the DIA'for insura of this statement maybe forwarded to the f�fie of andER a fine overage ven on, ?by certify un e se sins a penalties gip-jury that the information provided e_ p ed above is true and correct. Ipp- _ -4,- 7�� Date: la i aof• Thp town official. • r Town: ff g Authority(circle one): Permit/License# rd of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ct Person: Phone#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4, : CITY _ Y( \ ( 0 11) li l PERMIT# /..1�,0P" /'—°0 57 r�' y MA DATE JOBSITE ADDRESS 116_ G rat tdo St e rn_ OWNER'S NAME Li rh'Icnd CrIrd P_-l I 1 GOWNER ADDRESS 13 -. . OQI!Y1_ TEL0)" -./v141 r FAXL I TYPE OR r1701 PRINT OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL L. RESIDENTIAL�— CLEARLY NEW:0 RENOVATION:C1 REPLACEMENT:I— PLANS SUBMITTED: YES❑ NOQ APPLIANCES 1 FLOORS--I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER !, a cyv� BOOSTER ( 'J CONVERSION BURNER iii7iiiIII l . .. DRYER CE #IIRRRRURURRWU_FIREPLA F OR la 1 ` • GENERATOR IIIIIIIIIIIIIIIIIIIIIIllIlliillIllMlIllIllUM111111111111111NillIll11= GRILLE -i INFRARED HEATER REM. LABORATORY COCKS ' I I�fI � 11111,_ MAKEUP AIR UNIT 11111111111111111111101111111111110111111111 OVEN POOL HEATER j ROOM/SPACE HEATER I ROOF TOP UNIT iiiiiLiiuiiii TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I OTHER —— III 1 ligEgliIIIIIIIII - -- — _. . imomosixonomo INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO [II m I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 1 LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY LJ BOND t.. — OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the a.- Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER I I AGENT El 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 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 compl ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �4,6 PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MP L MGF❑ JP❑ JGF LPGI❑ CORPORATION 0#1 3281 C_ I PARTNERSHIP[]#I I LC❑#I I COMPANY NAME:I EF WINSLOW PLUMBING&HEATING 'ADDRESS'8 REARDON CIRCLE J CITY I SOUTH YARMOUTH I STATE I MA 'ZIP 02664 TEL 1508-394-7778 I FAX'508-394-8256 1 CELLI NIA IEMAILI accountspayable@efwinslow.com 1 O 00 i � "I u1 174 A Ilb. 3.+V/l RlI2V/Crr6.6¢6wb Vlg 1r1663vaiLQ663J666J 1 w= t Department of Industrial Accidents --_— �6,'-,.Y1�_ Office of Investigations - ;abf. _• 600 Washington Street __'� Boston, MA 02111 �'-, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): E,C-• V�i�j1Ov,r 00:A•.Oktn," 'Q , Address: C{Q "w1 t C a Q.- UX City/State/Zip: Sc,,-w\ YCY-o-c ,k., NA- Phone#: `5O3- 39`i r7 Are you an employer?Check the appropriate box: Xi am a employer with 7� 4. Type of project(required): ❑ 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. [] Demolition working for me in any capacity. workers' comp.insurance. [No workers' comp. 5. 9. ❑Building addition P ❑ 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.❑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' comp.insurance required.] 13.0 Other thy 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. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site tformation. tsurance Company Name: ICr _' CiJ-t o.\ f,` n c .. -f -i� olicy#or Self ins.Lic.#: ' $ a I A' Expiration Date: (—i - a6Y) )b Site Address: 3 G \c�,'1 c J4 � C��e`�,kj4 I.�'(( � City/State/Zip: d,-)L}(6 7 .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 against the violator. Be advised t at a copy of this statement maybe forwarded to the Office of tvestigations the DIAfor insura overage verif a on. do hereby certify un e ze ains an penalties o pe jury that the information provided above is true and correct. ignat4 : Date: la 3 i 1 at4 hone#: sy - 7 77K 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#: