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Home My WebLink AboutBLDP&G-17-005908 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK NI i� O. MA_ _ D E L PPERMIT#13LoPW-0°6 /- _ AT . '� OWNER'S NAME `� , JOBSITE ADDRESS k//,SFr' Qj r / i ^ c /9//c) _,� _ =y , �� OWNER ADDRESS 1 dI/ ' / 1 //7 z / ,� TEL 77 4 7%9 6-g14 FAX TYPE OR OCCUPANCY TYPE COr!MERCIAL® EDUCATIONAL RESIDENTIAL Li PRINT ,- CLEARLY NEW:LJ RENOVATION:I:] REPLACEMENT: PLANS SUBMITTED: YES E Nowt- --'*---- FIXTURES 1 FLOOR-a BSM •1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I ih TL_� (!-11-') I iER' 1,�-'1 1 I_. .l _.-1h,,k L -CROSS CONNECTION DEVICE •(- --.1 1�-1 TT1 I� rE--L-1�___._((�-'I- `•1.. 1 _.__ ET DEDICATED SPECIAL WASTE SYSTEM ,r II,. r._P 1F ,,ET 1771 u 1, h I ,J•� 'I _3 DEDICATED GAS/OIL/SAND SYSTEM I , :I_ ;E- (�-r-11... �r �17 (+--L--F . l C_-i tE DEDICATED GREASE SYSTEM 1. Tz:1_ I. ',1-- -1J;1,�.:,_ t,�- _i�___�__�L-x ,i _ ._II_ _ __ f-tI-_._._[--I-- DEDICATEDGRAY WATER SYSTEM z'1 --[- r , =,_1, „„j _ :Si _LTT: �-11. - .--r1.. :; -1I-^• DEDICATED WATER RECYCLE SYSTEM r_._..Y-,;r r _...,..,[„ ,��..[7.-1.][ 1 _:_.:.1.7.,-1_' _7731.,. .-1Ir--=!!1. .:p1�_- -i DISHWASHER . I -,-� _ DRINKING FOUNTAIN -F, _-: 1-J — .7'r-��11— -{F �-'1.- ''I- I—-.__ 'I --I_-(z-_-�I, FOOD DISPOSER I___i1 __ r.-C- i�-1 ;1-- [ . I- -I -i1--- 1-_.1 E- FLOORIAREADRAIN I _.R,�L...�_L �1_ . l-j-jhl-d :.I , 1_ ( __1. 1 r r INTERCEPTOR(INTERIOR) I ____'lr_ -_1(-_ It.-_-.1____ ._{1_-._'1 I[� _._. I -1. ; il,.,, -1��,: -7F.:` KITCHEN SINK 1 --'IT_;LL_ 'I^.1-•PI. �.,r_ I—._1_-__-_.I-_-_•--,1- -1 _.—I LAVATORY (--- [7:i l_:- -1 l y_ '1[--u1::: . ,4 :17 •11 J 1_— 1-_ l ._ ,.. �` _ROOF DRAIN 1 ,,,,il .I --i r _.il I� ._ ;I. . �r it r( [ l SHOWER STALL I.-. J[ lh . . . i _ Fir i 1--11- �1 11 -- it 'I . '[ -f: 1[ SERVICE I MOP SINK I. - �-�[- ;• -,11 11 — 11- Ih.--'L 17 1L ;1--: TOILET I,.._..!11..-�,. 1=. ,. �I _:_L_- -ii __ .tl 11_,_._._.1 '[-';1, . ',1. .1�-. L.-- URINAL 1-.-T1r '1. . •,ir- '[ P ii _': i r.. [ 1- -1[- " I:t �. II 1-ILL__ WASHING MACHINE CONNECTION I yl :r--1r- L-. .-1N� !I I1! 'FIT'1 1. �. ___ WATER HEATER ALL TYPES LLJI . .7 L _,_I_ __'1 77 jr"___,...1 l_ . _ _ I- ___ WATER PIPING 1-...,. ..11 1— r ir' - 1-_:-,l 1[--'L 1-'r-_ [--,Ir r.-.kl- OTHER (-_1E777:p '1—_ ' - 1�-11---I _- I- r--i1 _ `I_ r =-=�-= ---_�s.�__. _��_ '-.-; —;�- - r •i~ � 11 '�.-I--- Imo,_-_1 --I I I `-_ 1 :_ �- � �._t n A F Y I�_ 1 ....I-- I- . ,1 _1:- (-.1_ 7-1 _ I-u i IT T 1- _ ----1.1. -- .�,1-.. E-:_ C.- +r7T;.sue __ _. lr,_ .,-'�. :.,_ [�`•1-.-;I ,-_a T INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E' NO L1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABI'UTY INSURANCE POLICY E✓ OTHER TYPE OF INDEMNITY® BOND u 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 tru'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.1-nce with all Pertinent yvIslon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / (f_ PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 i SIGNATURE MP EI JP D CORPORATION 7 1# 3281 C i PARTNERSHIP D#r � 1 LLCLI# i COMPANY NAME EF WINSLOW PLUMBING&HEATING ; ADDRESS 8 REARDON CIRCLE ,_,.-,,aa CITY I SOUTHYARMOUTH _ 1 STATE MA ZIP 10,204 TEL 508-394-7778 FAX 1508-394-825d CELL I NIA 1 EMAIL accounts ayable@efwinslow,com _a_ s ___, .1 Department o,J.industrial Acclaents 1 rY0M / Office of Investigations „ e'-, o;:ill 600 Washington Street 1._`tf= Boston,MA 02111 .. u�* www.mass.gov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly • Name(Business/Orggttanization/Individual):E,C•Wtr\Slowa YlV�1Oi✓rc L 0<.0. sisC, c®)Ir-1(, Address: g t,Po� C)2.�. _ Q D City/State/Zip: Sosk ' ryYwnct.ii'is MP, Phone#: '5Db-394-l'11i1 • Are you an employer?Check the appropriate box: Type of project(required): XIam 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. 0 Building addition [No workers'comp.insurance 5.❑We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their i.❑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' 13.0 Other comp.insurance required.] lay applicant that checks box Ill 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. :ontmetors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. m an employer that is providing workers'compensation insurance for my employees.Below is the policy and Job site 1 formation. /� �_ ,.,,,t isuranceCompanyName: l TTl) "`Ik0•A l ISINCA.6(IL C 01iv`ick 1 olicy#or Self-ins.Lich�.^^#: 0' '.1 A Expiration Date: t—I" aol� ib Site Address: 3 Crv,rnanvNea-l{"h )0e311,1 i' kl City/State/Zip: 6„1"-I(6? .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 ad�ainst the violator.Be advised t a copy of this statement may be forwarded to the Office of tvestigations the DIA for insurap verage veri a on. I. do hereby eerti ern ;Cis an penalties o p jury that the information provided above is true and correct. ign Date: la)31)aotb' hone#: SVl 1114 777X 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#: V MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =,i_}. CITY /7 — __........--. . MA DATE - I P 'MIT# P"/7—60 71' ......_ _ ___._ .. _____i_ ___ ,_____,.,____=_,__,: JOBSiTE ADDRESS/ „ l' f Ce-k G1 OWNER'S NAME �ir�� I MP OWNER ADDRESS -1 MP TE INEWRI ITFIFAx 1 t.. P ORPE OCCUPANCY TYPE CO MERCIAL[`, EDUCATIONAL D RESIDENTIAL ., CLEARLY NEW:EI RENOVATION: D REPLACEMENT: . PLANS SUBMITTED: YES(} NO f-- -► BSM 1 2 3 4 5 6 7 8 9 10 11 13 14 APPLIANCES 1 FLOORS _ _ BOILER :'___..___;i :I...+.� , _ ; �._.. . _II_ . . i. _ .li, �. . IL _ .._ !__. . i +I _ i•i.. . i • BOOSTER i _ i I.. . I. ,,1�~ _'I {I_..._. _.,I yw . H I... . }f . ...-if- l ( 1,. CONVERSION BURNER __,._l I. I C. I __AI__J �+ I,.w.. f 1 -.t 1- �I __.. ...1 1__ I I �� I� r COOK STOVE ; . . I ' I .� .I I — 7'i._. .,.. ':~._- I l f� . - 1.1 y I_x 1 i _.I I._. ..11_. _. DIRECT VENT HEATER I A _� . fa__ 7.!i s I�_ . i 1.. . . _ _ '17.._ ( #_T 1. .- - -i �-------! I.__ ..11.E �.f�l�. _� _ ...�L.. .._ .. _ . _ _ I. . _y�l.� � 6=...• - ' � DRYER I ' I 1 ( , l I `I _ . `_ _.,1._ _.11. y_ .. ... -.III.,,;,I.. f 1__ ..--i 7- _._._ _. '-. _. ., -_{'_ ::1 I. I i ; FIREPLACE I� I.. !. . I w-. :p .. .. ,I .� ._ . . . . : '.- •_� lI - ,,. I W `-FRYOLATOR !_•{ I. I ; I.. . li ;5� _ 'i� i I rl_ _ '"" I�-- {(�- "� FURNACE i 1 I , �_ ,�I :I. z 1 .i I_ i --!.1 i ._ _ . _ - �` GENERATOR l _-71 1 --.. .- 1 _ -_' _.w... ' _.... " .�� _.. �_. I . : !.._::.r _�: GRILLE ' . i I r.. . ' ...71.--__- I'_ �'t l_ .i� ,I_ I._ .,i . . . i__. W i I,. • t,I INFRARED HEATER i . �; ` i i.... - _- `1. i LI.LT-I' EITc.1TIILi...... • LABORATORY COCKS i. - I.-�_ I _ . - 'I 1 �_. •_____._.- I . . _,c i_ MAKEUP AIR UNIT �- _ I I 1..----i'1`_ r.a _:1 I'' . _.'i+ _ `_r� _'' '—.__ '1 - - .1 - 1.,___ :1l-7l--_. OVEN l— _fi II� _ . ..1! -I1- _ 'ih _-l'_.:.. _.. I _--_li_. �_ 'I_ --__- i-.----).1--. ._ . �f I . .!_ . ih+ .POOL HEATER I . . . . . I "_ Til _ _;1� -, ... _ 7- �- Imo-t sr T I � -1 r I - ! ROOM 1 SPACE HEATERi_ _►1 _it___ 1 .. 1 _ ^ - • I 1_.._ 1- __�'11� (_r. 1 - li I i I— ! II-. 1 # .: ;I • —'i.. �•1 i i it .. 'lit f i..._.. t I l ROOF TOP UNIT -- _- -� - .- 1—...--:-..—_ ---_. ''O I - L. �_,._ ,lam �_ �p 'I � i� ,L_._�. � ,� r'-- - TEST _..._: a �.;_ -- --__ I Yy .:it1 t 1 I i ,' UNIT HEATER • _ i i . . ''I �i _ ;.L _.. . ..1_ __ r D ROOM HEATER i i . �) . . (- � ... I._ . _ _ , ___r �. . f� i1 _- i i...- UNVENTE _:. �._ _ sr�,F . WATER HEATER -_��,� _�__ _ ' I� I I_ ' i l�' '�I. , ,j ir.._' I� ,.I-- Jr: _ �1— ��.tI. . . i OTHER _.. .._ --- .- ; I _—.__ --�•- �. —. _,_ _ __ I —.: ..-j--r- .._._...... ::'r .._..__'T.._ I_.- 1 .. L.-.. -r• ��ry 1 1_._ _l� —•1. — �. ...._.I _�_,, %I—~ ... t l I I ... , i. :.1- - y.Y�ISWflVS�1.1.�CWt%. 1A,�I..tT1w.NF.h..-.a- IIMAP+�M^I�Mw�i• _w.w.M. .... _y_� ._.a. ,S .r .J.i�T. I.. I ,F. } LI ,I 1 , f I - ;r:r.z.r a r-rr•,., .,_yrt re >= r`�sxr+rJra.1' vt:n,- irrr._-.r: . . .. .. _... ... _. .. _ _ _ Y .�+r-:�i--• �-�ac_�z +.arsr�i tra-�ym �:-.nucr-- n•r '�...;..'.... INSURANCE COVERAGE insurance policy .or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO i I have a current liability I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E; OTHER TYPE INDEMNITY E BOND 0 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 Ej 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 complianc with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — ..4.--, 71(--/./....4e..,- - �� UMBER-GASFITTER NAME STEPHEN A. WINSLOW 'I LICENSE # 12298 ' SIGNATURE PL '� LLC # 1 _., JGF 'l LPG' CORPORATION 1 #12281C -11 PARTNERSHIPS# � .,_,...�.._..._�1MP � MGF� JP �� L�.! � PLUMBING & H 8 REARDON CIRCLE - COMPANY NAME: EF WINSL�W � G EATING__- ,�--� �ADDRESS ZIP 02664 ,!TEL L508-394-7778CITY SOUTH YARMOUTH ,�_ _ STATEDi'� FAX- X~508-394-8256 CELL N/A I;EMAILj2untsaabIe efwinlo .com _ _ - � ;1: Office of Investigations E �'him 600 Washington Street .., `Vl,a Boston,MA 02111 ''',-,,,,:;,,sewww.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers • &JBlicant Information G 1 /� Please Print Legibly game(Business/organization/individual):1�,C•Wty's$lOtN OVn,.( ytc y n 0 �taf'J1Q_ �i2)lo'1C. • #ddress: '' �.?ortievl CItt.t.t?. t1X :ity/State/Zip: Soy kv' Ycrt"-M..,,,Ft-, Kb,- Phone#: 5O$-3c19.'177 V1 ire you an employer?Check the appropriate box: Type of project(required): tcll am a employer with 70 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. [3 New construction 0 I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ['Demolition worldng(for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5.❑We are a corporation and its required.] officers have exercised their 10.0Electrical repairs or additions ❑I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. mtractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. tm an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site formation. nn surance Company Name: l' f'O',J Ck'ih-uaA1 . Jsovv,rtc `t� etv....Nevt....) dicy#or Self-ins.Lice.#: ($k I A • Expiration Date: (—1- ]D11 b SiteAddress:a3 Cclnnmovi -'- 0-411 A,l,e) CtRAILli" NI City/State/Zip: 00,4 to ftach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). dlure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a le 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 'up to$250.00 a da a ainst the violator. Be advised oat a copy of this statement may be forwarded to the Office of vestigations the DIA for insurer-,overage veri,f�on. / to hereby certify un ofains a r penalties o' jury that the information provided above is true and correct. paratu4• °/ --LA,r - _ Date: 1 t 3 t 1 aOl b lone#: i•35`t•777X 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#: