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HomeMy WebLinkAboutBLDP&G-20-000344 _______,. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK kk,,.._1°- CITY - ' MA DATE "ez... ----: laiall PERMIT# ^�- 9, y JOBSITE ADDRESS I a id_Ru i.e.-_(ep_._.__l6ym,Y-- -OWNER'S NAME mamma TEL __ _ MINI FAX OWNER ADDRESS - TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIALLY PRINT ^/ PLANS SUBMITTED: YES® NOD CLEARLY NEW:® RENOVATION:® REPLACEMENT:1�.1' 9 10 11 FIXTURES 7 FLOOR BSM 1 2 3 0 5 °- a --� . '� BATHTUB ".an®m,®® m n . r®®® CROSS CONNECTIONDEVICE ® 'm n ,�Wi M;®O�- DEDICATED SPECIAL WASTE SYSTEM ®� ®® n- i DEDICATED GASIOILISAND SYSTEM MI an®MNw ® owuml® 001 �_ONImoONN®® DEDICATED GREASE SYSTEM®t-- r ®(W '®a ®I DEDICATED'GRAY WATER SYSTEM ®um®ice um�'® DEDICATED WATER RECYCLE SYSTEM ®®® m ®(®j®® aill WI DISHWASHER - - ��: WI, i �W_ IWII DRINKING FOUNTAIN NN FOOD DISPOSER �I®NM� ®®®®' -- FLOOR I AREA DRAIN ®—®®'®�®® ISIN INTERCEPTOR INTERIOR) I IIIIIII MINI INN®®�W�.�,® II IIMEREMENIIIum ma 1111 _ ®SNA ICE+(® ®!- LAVATORY �®_ '�®®®I®®®11111110.11101101111111 ROOF DRAIN —MN� ®®®11111111111111111111F-1111 MA— ;;®III SHOWER STALL I - IN SERVICE I MOP SINK ®®—'®in Im Imo( ®M TOILET ®a M .4- ,: N W URINAL ®i®I WASHING MACHINE CONNECTION ,M1.1 ,. 1 NI®'�—U1i® ff ,S WATER HEATER ALL TYPES I®_ n .®=1= .C4 �I —l W WATER PIPING ®®'M ® 0 ®i'� _ -- -- OTHER 1 __ _ ��®�® m,® N .O ®_ _ i (�r�,�®lam r y W --. Iiillimi Mu limo ME ON No am EN I=MEM No gm MI gm INSURANCE COVERAGE: T l have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[] NO 0 �O^ V) IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY BOND El 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. AGENT CHECK ONE ONLY: OWNER SIGNATURE OF OWNER OR AGENT are t�-� and accurate to the best of my knowledge I hereby certify that all of the details and information I have submitted or entered regarding this application and that all plumbing work and installations performed under the permit issued for this application will be in co Fiance 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 MPO JP® CORPORATION# 3281C PARTNERSH I PO#1==1 LLC - COMPANY NAMEI EF WINSLOW PLUMBING&HEATING __ _I ADDRESS 8 REARDON CIRCLE —.--- 'STATE MA ZIP 02664 TEL 508-394-7778 CITY`SOUTH YARMOUTH _ -��---- FAX 1508 394 8256EMAIL accounts ablecom I efwinslow.CELL�NIA - ,Rff `fib /) The Commonwealth of Massachusetts �� t Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 .9b vv` w ww mass.gov/dia uno 5 Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):E.F. WINSLOW PLUMBING & HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): LID I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]I 9. ❑Demolition 10 Q Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.0Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic.#:1909A Expiration Date:01/01/2020 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine 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 of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and e pai lid pen lties of perjury that the information provided above is true and correct. Signature: o 41,- Date: Phone#:508-394-7778 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#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '_ � '� PERMIT# �f 9 ;r, CITY I\IC DI���.. ......__._._.__ •....._1 MA DATEI_7./i�2._1 R...... .1 JOBSITE ADDRESS 1(a-k.R.Ps,4 c(oil.Yaymari"f""``-WNER'S NAME Wen..69v. --•-___._...._. G ',Drag__--. ,--._ _ ... AX — . _._..._.- ----------- �.__._ ITO5..l2z27-G,e5V.IF OWNER ADDRESS , TYPE OR OCCUPANCY TYPE COMMERCIAL[, EDUCATIONAL 0 RESIDENTIAL[ PRINT �� CLEARLY NEW:( RENOVATION:D REPLACEMENT:I0/ PLANS SUBMITTED: YES0 NO[ APPLIANCES 7- FLOORS--► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 r BOILER _ _ ��IIm_—_.��®®' Boo. mnow•mmite®mi CONVERSION BURNER wwwi COOK rt !INININCIMANIIMUMMOM® MINM EMon DIRECT VENT HEATER IMIMMINOMMINENNIMMINIMINniminEWNI FRyouToR LW_ _ ML®J_®IMIMM®INM®M MINI ®' . _ . II _ INFRARED HEATER L.MAIMMMIMI— .__...I L _i=L--I _._..'I - NM LABORATORY COCKS IMIE nsuffon .1 Imi J... . ..II_.. I.4�® MAKEUP AIR UNIT ®®m®-��� I�� m�®m OVEN ®MMMI®IMMEMMIIWIIMIN ®M POOL HEATER MMM IMM ®MMM—MliMM n, ROOM I SPACE HEATER ---1011.113-"IgnaMilliMILM --/ UNIT HEATER MMMISKIMMLMIMMIIEL_MXIIIMM a UNVENTED ROOM HEATER IMMIMMERIIIMMniornown.. ..MOACM , _c1) WATER HEATER ®M'®®I.. .- ®®®I®I®®M®fWS ANI®®®®L_J®®I®®�- ®®I"711- ®®®asmim® INSURANCE COVERAGE I have a current Iiabili insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES El NO [] I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER El 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 true a ccurate to the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be in complia e th all Pertinent provision of the •Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • v PLUMBER GASFITTER NAME STEPHEN A.WINSLOW .. . . ,_ . . LICENSE#.:2298•. , SIGNATURE MP D MGF 0 JP© JGF 0 LPG!© CORPORATION D#13281 C___ _ I PARTNERSHIP D#I . . . :I LLC 12# COMPANY NAME: EF WINSLOW PLUMBING&HEATING ,ADDRESS 8 REARDON CIRCLE CITY SOUTHYARMOUTH _.. STATE MA 'ZIP'02664 ITEL 1 508 394 7778 FAXI508-394-8258 I CELL NIA EMAIL accountspayable@efwinsiow.com — olc- /li/z7 , i The Commonwealth of Massachusetts t- Department of Industrial Accidents 41— 1, = _. 1 Congress Street, Suite 100 1: Boston, MA 02114-2017 �'r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):E.F. WINSLOW PLUMBING & HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 88 employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13. Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins. Lic. #:1909A Expiration Date:01/01/2020 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine 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 of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and e par s nd pen Ities of perjury that the information provided above is true and correct. •Signature: r - „DA._ _ Date: Phone#:508-394-7778 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#: