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Home My WebLink AboutBLDP&G-17-006741 - MA S CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 0, Er. - �.0i CITY i lyl DATE ? G4 PERMIT#1,40A17 7 - / JOBSITEADDRESS yQ� �%f `%J ". '"�I OWNER'S NAME L'�. - i t pOWNER ADDRESS I —� j TEL r� ( gQ 4 S AX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL[U_' EDUCATIONAL r RESIDENTIAL:1--- PRINT CLEARLY NEW:D RENOVATION:E REPLACEMENT:' PLANS SUBMITTED: YES L'I NO - NiFIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 t. BATHTUB —i 1_r 1_ .- ,,,_- r. .I 41 I _-',[ I s ._ I r-'I . .k CROSS CONNECTION DEVICE I 41 _ L ,--�t i.. 1,.- _Li3_ _frT-r_.T ... - �_.___ -- DEDICATED SPECIAL WASTE SYSTEM !11 . . .11, Imo- - ,L ,I- I-___,_1 I._.. .i I._ L��: L-_ 1 ._" 71 -7 r--L Iir ®r DEDICATED GAS/OIL/SAND SYSTEM I r-_ ';(�-,h� � ;i .. DEDICATED GREASE SYSTEM I`. 11011.1 ( 1_-_ -_:(��®MI DEDICATED'GRAY WATER SYSTEM UI .. rem mr L L aim_--('-. DEDICATED WATER RECYCLE SYSTEM IME-7.77 F. _. _ ..21=1.1111111MMESME111 Einnin N m mit_ _.� _ m . r INTERCEPTOR INTERIOR ______L Li i (_" 7 '.._._ MINIIIII---._-1 _ .. ®_i_ LAVATORY• I. .,, 11 ROOF DRAIN must r--:m1___IMMI(_ SHOWER STALL MI a�rmL_-_7 , ir..-,.fir- � m� ��r--a SERVICETOILET 11I .T. ffillailmiliiI r ' URINAL Mar ��[-- `� [�r..... [ ICE VVASHING MACHINE CONNECTION M. II :F.-.ITIMITIM11-71117-1111111.111111111 WATER PIPING —iin�- ��r m� i®®F I OTHER . ... .. __.,_ . _ _ r--II_-_Mt . FT--'� r . I .._. �I I--i��L- _. F. Lr .1P NET ___ - _ .11. 1- 1y— ILL -'�i�-'I� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITY® 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 ® 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 tr a,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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,/ -� e�.�L/iV,# -�Av., PLUMBER'S NAME STEPHEN A.WINSLOW_ . 1 LICENSE# 122 , SIGNATURE MPI JP Di CORPORATION D# 3281C PARTNERSHIPEr#r_ LLCD# , COMPANY NAME EF WINSLOW PLUMBING&HEATING i ADDRESS 8 REARDON CIRCLE _---1 CITY SOUTH YARMOUTH _ _STATE= ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountslable@efwinslow.com Department of Industrial Alcctaenes I'— -='t Office of Investigations —„� 1=, g e= inl_ 600 Washington Street ')EIE1=; Boston,MA 02111 • '--4...-.., - www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):E.c•W inn 5}nv� ke,CcAekccj 22.atQ�.1 c,,„.)1'- . Address: Ss KPO� C-',(Je-- City/State/Zip: Soo it'‘ for -4" NPc Phone#: '50);-3\9 11?c•1 • 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. 0 New construction employees(full and/or part-time).* have hired the sub-contractors Remodeling 10 I am a sole proprietor or partner- listed on the attached sheet.t7 g ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9, 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their right of exemptionper MGL 11.0 Plumbing repairs or additions V.❑I ys a homeowner doing all work g P 12.0Roof repairs c.152,§I(4),and we have no p mysrin e required.]workers'comp. employees. workers' insurance t [No13.0 Other comp.insurance required.] thy applicant that checks hex 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. im an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1 ermdtion. isurance Company Name: PP int.....-3 rkv k _Lc\f Umk.l Cf2" ` u1r". vl,-f olicy#or Self-ins.Lic.#: \5 a I A' Expiration Date: t-I^ ant-) rb Site Address: J rv\ctri w20.1 Akt-fly 0",23'h`krl' I'Mi City/State/Zip: O, 4 ls7 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 a:ainst the violator. Be advised!bat a copy of this statement may be forwarded to the Office of tvestigations. the DIA for insurapetoverage yeti ka on. r do hereby certify unr• ,penalties o Vjury that the information provided above is true and correct. (( .1 . _AL._ ( . I 9.0(�, iu atu?= hone#: .ShR.3`1`(•7 77D 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#: MASS HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK l-_ j= 7 CITY '' . --_._�-- --...��. . MA ATE /9jL : 7-�i(J& WitXAI?//2 PERMIT# 1 ' JOBSITE ADDRESS _ •' OWNER'S NAME IDIPPARMIXIMINFri G OWNER ADDRESS — TE J'� ._._.. _.._. .._ ___ __ .. .. I V A;i ' FAX _ s TYPE OR OCCUPANCY TYPE COMMERCIAL Li[ EDUCATIONAL � RESIDENTIAL CLEARLY NEW:Ell RENOVATION: 1 REPLACEMENT: PLANS SUBMITTED: YES N0�%� APPLIANCES 7. FLOORS---* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 I. .. , I....-__ :1. _. M .. . _'r.::: . li_ 'i. . Ii- 7 }I- .-_ 177 i - l f I-- . rT`1 BOOSTER •; I F' .. _� _..-.,-�. .._,_. .�... �_ - _ �_ _ i .._ y . I. I aI. �I�._ . 1. . 'I "i. - I- ;�._� .s tL. W �. ' "3:1CONVERSION BURNER �.T,1._ E. Il +...__ _ 1,.. . �i I_ i . 1 .__. .--. I� :I ITT i I ii E COOK STOVE 1_�- --- . . . ' I ...i l 1 +'�__. -- i I . ..=;J4 .._,,� _ '.J. i 1� i I----- - L.. (I DIRECT VENT HEATER 1.. - - _1 I_------.i I .._._. .°1_ .-7. I.._. I..... `.17. "-,11---_4 1—_-_. i_."_-_-L;1 Ti I.�_7 J.�.—_ . 1.�. _. DRYER I._. .A_,: h - 1-1 `1.��_..-,I _ ,�_..--11 -...._..-, . -� --. _ '- -"--- - — , ° i FIREPLACE I 'IT— . 1-- - _ - '1-----_i'l---- -- - I—_--_'-;1----- -., --.�-: I i FRYOLATOR i___ . i I. - I . - ., fw-.__ I._.._ ,I . �•,;I-- -__i 1.—..�__ _.._.- _� l. . _ z► y__11 _ I- I I. I- � I_:_ `� FURNACE I. - ` 1-^. .: I : . I,u-..� I __ :- " :_..V" - } �_._ :- - `"�'-----jr----' w ----j. i 1J_- 1- i i 1- I - i ! I f i i t , _GENERATOR L. I- .- I+ .. -f- --6 -`1+ ,I I J. jam._ ; -).I_ 7.t., GRILLE {�. __..• I i I . l . �l •! ,J.. �I�__...._ lI . ' I I:��_:,.,�_ .. fI--_..11.7 _.fi I_ 'i INFRARED HEATER ( h..._ :, I—.� ��, ,i:...,,_-1!I . . `I .� . Imo..s I . i - --H ;1.-.• _"I ._. ._'I .._ . �' .:1. �' 1 • LABORATORY COCKS ,I___.__..__ fir... I-. . 1_ . . .. -- _..,J �_. . .= I----..-_ I .. ___-. i __ I _�1--___-., MAKEUP AIR UNIT I- 1.I.�_..' I- ; 1`___ i_ �.:;1:..__.-Ii _3i"------`�=- f_ --' tl. - 1 . _.'i Ir� _ . I I _ _ : I; OVEN L r_,=t 1 . .. _► Imo. 4 I. _C 1_ 1_ _--' I`_�__j i_ I __ _ 1. I.I . 71 I . _`d!_ --.�J----- POOL HEATER Jr.T,z- I. . . .T1. . 1___ _;1_ . _.. .i • . Id •__II ji„ .Y fl_ . qJ. il, _tl_ „„!,i, �i• �_1 ROOM l SPAGE HEATER •„--►1 . ._.__11... .._ L. . . t 7—, 1 - i.—. -____�';1 _.11r �+~ 1�- .fir Si ., . =- �_ ..---f -1 - ROOF TOP UNIT H 1_. ,_� � .i I ��. °�._ i -1 iI_......-..A.�.,..-c I�'"'�I"'-""�;L�.�.w..� ''"'..'•�'�~~.,.�� TEST 1 _ 1,. 1 I $ . __ .1 J.�._.� UNIT HEATER 1p. .. _ •T -_.. - �.�,.._; UNVENTED ROOM HEATER .L I I _':I- --- , 1-_.__. ii. .. ` i;-- 1._ - - — I . - ?1-- .`—.F T .►1-s - t(. - L��=..,. WATER HEATER ,1 _ t t i 1 1 � 3 OTHER1 _ .... ....._,__- ..— ' ( ___- ._11. -. . !.1-----_...•.-e_.awTs.•�+n� -.-.. _•..._.......q.u_a.•._w._.s.�..a-a...�.�_n.._._..___.. ,wTR�_w ww_�w.-._�-.- - .._.r...._. I . 11 _ 1 I. _m._-'' _ ...,. 1,~... f ;� 1_��_._ l 11 -- -._ I.t=(I . . _ i ' l T I .. . I. . 11_. _ I 1 1 I ,I_____•I ' 1 I __ — _.,_,; I ' I. I' ..w... a..,:IA tines.; . - 1 L. —�� r— I.. - II 1._ _ . _i i—•___''(_ __. —1 1 �_ . I_�.=__ 1.�.,,_.�.-_ 1 ..a:,'rr�r• fir I - �" -I try ` '.lart•, _..._._ _. —. __ _.tsar• .++-stZ-' rh'::r�•z �•s:n r^�:rr+ n•• _i lr-r.:r�:z ._.�... -,.r*rr.• I I•a s:�.rs r�.r:.�:I'.rr�armzT. .,x �: INSURANCE COVERAGE I have a current liability insurance policy .or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES f NO �i 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Lc OTHER TYPE INDEMNITY ( ,,; 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 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 Issued for this application will be in compile e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. rti> (11. 1( PLUMBER-GASFITTER NAME STEPHEN A_WINSLOW 1 LICENSE # 12298 1 • . SIGNATURE MP El MGF D JP Erj JGF El LPGI D CORPORATION :# L3281C ' PARTNERSHIP '#1..... LLC #= COMPANY NAME: EF WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE 1, _ __ - SOU CITY [ THYARMOUTH STATE _ MA ZIP 02664 _- ITEL L508-394-7778 FAX 508-394-8256 CELL N/A liEMAIL accounts�ayable@efwinslow,com 'CL� r.&' .ran 1C .Vit• IIT.T.Q[T.L�..+s.ara,.sva.Gty ac -..a _•. •._• •. ..- —_ .l'"". W Department of Industrial!Acctaenes t —ft= Office ofInvestigations t„Nll_ 600 Washington Street _tlf=v Boston,MA 02111 • `,,z.o www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/PlumLebers Applicant Information Cbly b lj nn arnO(Business/Orgeaization/Individual):l.•'C•W:✓s` j�I evu Qt�'^^ 't`^c L. to Address: ' (CP S Cltae— City/State/Zip: �os kh 'if-"a"-1" Mpr Phone#: )b-3c14 117S • 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 7. 0 Remodeling listed on the attached sheet.I 8 0 Demolition ;.❑I ship a sole proprietor employeeso pertner- These sub-contractors have ing haveo meo inay workers'comp.insurance. 9. 0 Building addition working for any capacity. [No workers'comp.insurance 5. 0 We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.0 Plumbing repairs or additions •❑I myself.a [No workers'e doing allp work c.152,§1(4),and we have no 12.0 Roof repairs insurance r .] comp. employees. o workers' required.]t an 13.0 Other comp.insurance required.] thy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. such. Homeowners who submit this affiavit indicating they are doing all work and then hire ontrauors that check this box must attached an additional sheet showing he name of the sub-contractors and their woide contractors mustrrkers'co t pa new a policy infoavitrrmation. im an employer that is providing workers'compensation insurance for my employees Below is the policy and job site 1 ermdtion. 1 J C�JYUOjt yT� \ p�h LL�✓ty isurance Company Name: • olicy#or Self-ins.Lic.#: �` S•..1 A. Expiration Date: n11 >b Site Address:, 3 MM w t1 ea-t Ct . �1r ikill City/State/Zip: 1, q Io7 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 1'up to$250.00 a da a:ainst the violator. Be advised t i at a copy of this statement may be forwarded to the Office of tvestigations. the DIN for insurarpeqoverage veri.a.on. -_ --// do hereby certify un.e I penalties o Vjury that the information provided above is true and correct. 4 _` Date: l�. 1 9.0l �,r it.atu=: _ r hone#: •• `I'?77 Official use only.Da not write in this area,to be completed by city,or town official • Permit/License# City or Town: Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: