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Home My WebLink AboutBLDP&G-18-002991 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1=_, CITY n3/42 i MA DATE %/-0(% 17 1 PERMIT#,</.I/' /1g VOX-• / JOBSITE ADDRESS S� 7/2/1 gag ( t/ OWNER'S NAME Or OWNER ADDRESS ��'�f1�1�/ h�C�/f / TEL z1 is4.1.�;ip /JAXt 1 TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES El NOW G FIXTURES 7 FLOOR--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUBINErjM _; 1 :N[M ,�1� �CROSS CONNECTION DEVICE , i R, M DEDICATED SPECIAL WASTE SYSTEM 'IF-....1 SOK i aMEii . um DEDICATED GASIOIUSAND SYSTEM � �i1;� '--' DEDICATED GREASE SYSTEM 1 � 1 _ 111111111 _ _ . , DEDICATED'GRAY WATER SYSTEM ;,,,,,_ i ,�, ; . �' ' —' _ DEDICATED WATER ER RECYCLE SYSTEM �' it I— -) l _ .�- — DISHWASHER r . _._. DRINKING FOUNTAIN ' '' ME MI 'I — FLOORI AREA DRAIN I1 .I�--- ^- —_ FOOD DISPOSER I _. _ MillINTERCEPTOR INTERIOR - ,_— __ _ —f imig .-10 KITCHEN SINK r ■il1 i — r LAVATORYI. I � � .- l _ROOF DRAIN , SHOWER STALL Mmuit t � � t.,. . - . ' SERVICE/MOP SINK ,_�__.� it �i _ _ 1 I TOILET _ ,t iiinipmfflA _ IEN URINAL i �i�--- ;, . . . - - � ;I�N WASHING MACHINE CONNECTION i _ ' ! ,_ WATER HEATER ALL TYPES ___ , a i �t ' WATER PIPING _ __ --_ __ OTHERIIMM — I ,_��M!N` _ �__ I� _ . .— itm ifrailmill r - l_ _. , _ initilit INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ei I NO El 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 ® AGENT E . SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details end 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, <' PLUMBER'S NAME STEPHEN A.WINSLOW !LICENSE# 12298 SIGNATURE MP El JP El CORPORATIONW# 3281C ;PARTNERSHIP# 'LLCLi# $ COMPANY NAME EF WINSLOW PLUMBING&HEATING i ADDRESS 8 REARDON CIRCLE 1 CITY SOUTH YARMOUTH _ f STATE MA i ZIP L02664 _ 1 TEL 508-394-7778 FAX 508-394-8256 CELL N/A I EMAIL accountspayable aeefwinslow.com /• i > Lf2li- w_._ Department of IndustritalAccidents t*=a ih. Office of Investigations - __iVil—. 600 Washington Street _`1— y Boston,MA 02111 •t�:.. www.mass.gov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information f Please Print Legibly Name(Business/Organization/Individual):E•'r•Wi✓,S}o�N Qloo.,t7;rteet a.0tRA":� Qn.)I'lf• Address: ' (LP G C,rrtiP- , a City/State/Zip: Soo kh v^m k n MPc Phone#: 5Di c14-11-7SI Are you an employer?Check the appropriate box: Type of project(required): I am a employer with '70 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors Remodeling I am a sole proprietor or partner- listed on the attached sheet.t ❑ 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 10.❑Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.❑Plumbing repairs or additions I.❑I am a homeowner doing all work g P 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.] 1ny applicant that checks bok III 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. dm an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site 1 .Tormation. isurance Company Name: PPC ta'..s �� o.)1Zf '^C..12— ` n '/ft kii‘i • olicy#or Self-ins.Lic.#: 1''a I Pr Expiration Date: 1-I— adl7 b Site Address: ) Cofv-rv`ern5 eo.-kjrh ki'Q/ CFeA'5Y\` 111-\1 City/State/Zip: O, "'Il07 .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 t at a copy of this statement may be forwarded to the Office of tvestigations• the DIA for insurarpetfijoverage veri apon. do hereby certify unns an llpenalties of pe jury that the information provided above is true and correct. renatu . r Date: t a.)3 l)a0 k hone#: .51)R•351.7 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 Phone#: Contact Person: MAS ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `!' i '/ =WG1_: CITY el' ---__ ... .__. __. ....... .-. MA DATErtreT7 : PERMIT# /-�' -''1r-4'4'0 - 'I -__.._....- 1J21hi /`tf�� C OWNER'S NAMEJOBSITE ADDRESS ' , � GOWNER ADDRESS i 1 -1 TEL 1:' �7/c / lFAX il TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL ..1 RESIDENTIALD-/- PRINT N CLEARLY NEW:D RENOVATION: I j REPLACEMENT: I...‘';,'-. PLANS SUBMITTED: YES Eli NO1 S--► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 APPLIANCES 7 FLOOR 14 BOILER . ! I ._ '; .. -.. . _I _ i. . _ .li . . II. -- . ;1 i _IL .. r . _ _BOOSTER I _. i 1. _ I . F i ._.:I_ . . ...I ............ .,II_ r__-____ I-- _i - _, I. CONVERSION BURNER i :IW . T is I—_ 1. .. 1I ._y� Lam.;I .___. ..s I._ - _ftA- _-_ U._._ !I. ..: COOK STOVE - �4---. ,� �i i �_ _• -- - 1 . i FILL. '�� Il i �I.i... �, DIRECT VENT HEATER --�-' - '�--.- l .y- f 1_ - ; ^R—.+.__.,__7 1 . . .I...... .I...... �I- i 4 --' - - -- I!. . DRYER �` - - _ :L lµ• I- - I _ - FIREPLACE ,);--- 1�_! -- - � _ h zJ ' _�' — it ,� FRYOLATOR ; ; — 'r._,_I'1 . ., . , >1 __ `I. I_ . I ri_ .�,.. - t . E __- ' FURNACE `I . . ' I_ ' I _. r: . _'1- . .I. : I~_ i! : _. - t] _ -f ., GENERATOR -. `. _~ I�. .�� t_� . 1 _ Tf -�. . .:.�.:r. ......1..1 __: - �� ---- . i - � - . �_:: `- - - -JI- -,� I _ GRILLE f�� ' —v !----.-'('I--�...: "'_ I .._. _ 'I . J INFRARED HEATER - ;�.� _ _�..� �- �_ ,1 I . __ I_: _ : _. -� : __'1 --> LABORATORY COCKS __ - . . ' _ '_ 1 _ ,,1 --- -- I. .j` i .. MAKEUP AIR UNIT -_ -- . _. _ _.. ... ..._.... _ _� 1 _ f f f t1 -'�' . it . .....crs.,. ` .� �l, 1� OVEN '4 � I: -_.�' - �,POOLHEATER �I `I �I __: E1 __ - 1_- . � . . . .��I�.._ li �h—.._.1 _i .- . ._. - . . � �.-_ I. •ROOMISPACE HEATER . . - - I-- . .. I-. .I_ ;I `L_. r'I--- ,._i . . . - ", _r.--, w s. . 1_, .,I ROOF TOP UNIT w . 1 i ` ` L.- tF TEST : --- -_ I.. I - • . -:_ ._ ' ._ - - _' ,__ -. UNIT HEATER _ _ I. . . ':I .� 'I� _ . _.... : :.l_ . _ I, I I . . ` . i _ .. . I . .- - UNVENTED ROOM HEATER I _ �i -!.!_. _ _ 'r _ ',I. . . li _'l._ . _:I . - 'I__r _ �R� .i: (1 ...._., . WATER HEATER _/ 1` it . 1 _ I . 1 0 • I _ I— ;I i �I. .� - - ' _ . OTHER - _ __ _ -__. _ 1 L 5-1r1 l�f....^_ar) 1�'9tj� -- r-`•,-,1:.-- ts.-..-.._r S .'T;#.,. ( ' I.,...- -•a{Tr,•7—„1,......:RPt•.- ----,„..„.. INSURANCE COVERAGE I have a current liability insurance policy -or its substantial equivalent which meets the requirements of MGL. Ch, 142 YES 0 NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY El BOND L 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 S AGENT E' 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 compli "e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .< . -ii''..: _.; /2?,tiii‘e,/ PLUMBER-GASFITTER NAME LTEPHEN A. WINSLOW 1 LICENSE #L12298 - r , SIGNATURE MP El MGF D JP EL? JGF D LPGI LJ CORPORATION 17#L3281 C _11 PARTNERSHIP D# LLC I# ,_�� COMPANY NAME: EF WINSLOW PLUMBING & HEATING 'I ADDRESS 8 REARDON CIRCLE 1 CITY SOUTH YARMOUTH _ STATE MA !ZIP 02664 'TEL 508-394-7778 FAX 508-394-8256 li CELL N/A ;.EMAIL accountspa able . efwinslow.com i., , ' �t.-3 /--/-: (11- Department of Industrial Accidents t'-•ailP=ry Office of Investigations —:eM1l= 600 Washington Street r t''•t Boston,MA 02111 ,. www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information C /� ` Please Print Legibly Name(Business/Orlglanization/Individual):e.c•w,,„slo.l Y(VsnaO�rtect L k- \' , c .)IelC• Address: '' c .or.inn CI rat.e- o City/State/Zip: .Sou kh a`^o---1" NPc Phone#: '50$ `1-1T7 I 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. Remodel in ;.0 I am a sole proprietor or partner- listed on the attached sheet t0 g 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 10.0 Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.0 Plumbing repairs or additions i.0 I myself.am a [No workers' doing all work c.152,§1(4),and we have no 12.0 Roof repairs suan e required.]wor comp, employees. workers' insurance t [No13.0 Other comp.insurance required.] 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. :oyntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. dm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1 .Tormation. issuance Company Name: (r IY YO.•� CA‘) f l CO— ` o 'Vvi olicy#or Self-ins.Lic.#: 1$a I A- Expiration Date: k'-i` anl7 lb Site Address: 3 Co,rvsn'vcr/1 W{'o'iTh $l Cl eAtkA' i1\l City/State/Zip: O,)14 to 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$250.00 a da a ainst the violator.Be advised at a copy of this statement maybe forwarded to the Office of westigatiors the DIA for insurarpeeloverage veri on. ( do hereby certify Inv e e yairss an%I penalties o ppe jury that the information provided above is true and correct. e�f Date: (. _)3 I)a01 hone d: .Sll$-?,`Id-'I77X 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 Phone#: Contact Person: