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Home My WebLink AboutBLDP&G-18-001570 LC-x • TASSAC USETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK rff-Sli-'"r= CITY°-� phi a tr 9',h' a'� ° MA DATE_ �.,i p•-/z -/ 7 PERMIT# �D�/1-OOIS740 JOBSITE ADDRESS - 3� Glixza„ _ _w OWNER'S NAME�,' l% 2e-T r� ' p OWNER ADDRESS S /i} 7ij G" TEL ,p-3d d S.3,f FAX -1 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL"'1, PRINT • CLEARLY NEW:0 RENOVATION: REPLACEMENT:j( PLANS SUBMITTED: YES 0 NOD FIXTURES 1. FLOOR-3 9SM -1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 ; i r ! z.'a,I _ _ CROSS CONNECTION DEVICE `-` I DEDICATED SPECIAL WASTE SYSTEM 117 l DEDICATED GAS/OILISAND SYSTEM [Ti; r ; r F ' ` ii [7:1 — I,.._.. l-.-k ^I(J^ I DEDICATED GREASE SYSTEM lV ~�:I I _ll: _ f I_^ a(-_:�__I —_� __._!I___._:'(s-.I---_.. r �:-' DEDICATED'GRAY WATER SYSTEM (... F— ,_.;�^_z I -�L f =_t(_ ; FT.11 --. DEDICATED WATER RECYCLE SYSTEM r._..._,'I -- 'C-�. L, .:SI- 1...,. .. _1.,- r- DISHWASHER • Lrl. :I _ (- �h �sC� II .- Ik1-:.:4-1 if:4777 DRINKING FOUNTAIN _Lr�,.,.:.( )r .:l ? _- FOOD DISPOSER h�. 's�- [ -r . `h`iI_. -.7. I . ...-:t _r{n7.27 (- 7[ FLOOR/AREA DRAIN ��. __.;L.__--. (_,. 'L L-�1 - - - I. — _ :r;1—_._P.._; INTERCEPTOR(INTERIOR) KITCHEN SINK I ;1 II r-.[7 Ir-1r . _!'I.. .J-____.r_...._l� } LAVATORY I---` il__ .'.I _ f- I til.. _ '47-7-,'I_ __'(.. _ _�- ROOF DRAIN ,,...,11 ;Ii;l- r.._..:.11.._.: �---. ( -`(--iC r!�[ .� . ._ SHOWER STALL _ SERVICE/MOP SINK 1__—'�� E j =J 73_ it --.. w '__IL- 1., TOILET I _.._7�: [-7:d_. ._.'1 _:_a� ilII.. JL 1___ - --''- `Lz� URINAL _ __;C 'L :IC—_I r.T WASHING MACHINE CONNECTION • ."II I� I(+ (-_.]I IL I r-'� r l: 1 _. N WATER HEATER ALL TYPES _�,..-_11_. r-(r.. _%1_ . _'r—� . WATER PIPING OTHER T —__— 3 ET E.17 Jh ;I fir ;: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIIJTY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El BOND J-- 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 0 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 a ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. b A PLUMBER'S NAME STEPHEN A.WINSLOW _ __�]LICENSE# 12298 SIGNATURE [�/ MPS JP El CORPORATION # 3281C IPARTNERSHIPO#1 . LLC # COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 1 8 REARDON CIRCLE 1 CITY SOUTH YARMOUTH IJ STATE MA ; ZII? 02664 TEL 508-394-7778 lam/` f I FAX 508-394-8256 CELL I NIA 1 EMAIL accounts ayable@efwinslow.com c�ia Dep,clopneint cj'i cliastrial Acc fiaenrs 1 (- Office ofInverfigc/ro . l ph 1p _ i Il � f 6ing c _ Boston,1 4 02111 www mass.gov/dia • Workers' Compensation Insurance Affidavit:Builders/Contractors/IElectricians/PlU.1t bers Applicant Information i n + Please Print Legibly Name(Business/Organization/Individual): e•,C•kAl1vNSI ova Qt0,,k.io w�cj t�.a�✓ , col I�C. nn u Address: % (4 KY lull CI 21,1?— City/State/Zip: Soo ct'\ Y-orti,c,•r c4A- Phone#: S-3114r-11?CI 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. ❑New construction employees(full and/or part-time).* have hired the sub-contractors !.❑ 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 working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0Electrical repairs or additions required.] officers have exercised their L❑ 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.] 1ny 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. km an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site rormation. :J isurance Company Name: .,-} ('�v _ 1 ` SU 21-n C0- t vV`- . olicy#or Self-ins.Lic.#: \ciS a I A- Expiration Date: ---1 _ au---) rb Site Address:D3 Ortri Acril V Q jr``) A , e Allu'^ 1111! City/State/Zip: 0,)14 6 7 .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 a day ainst the violator. Be advised t !t a copy of this statement may be forwarded to the Office of • tvestigations( the DIADI� for insurarpee'loverage veri car. i do hereby certify fy under e ains ana penalt tiies of pe ju►y that the information provided above is true and correct. A ir 1 atu(res- �" Date: [L) :3 l 1 9.0 k'S hone#: .`Sf 7 •3`1`l- 7 77X 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#: -..` , ' Y S ` "_;f1 (C:y �E� t �j1 .� - R L ` [^ {gyp .Ri `---` V.L�p i�L�dD _��=c�J a�F�MC1�!pY eY°L� [L�Y` �+va�dG�f s'h21 7::.'. ,:-.‘.,f e a-.� i'ef�> ;.�i�s�a�6�V� c�F��JO 7�C(`t�t:"tl av itl8al 1 � ' CITY ;ik.,_ o ti r K T MA DATE -/1-/7. I PERMIT# nI> ?-®d`<6-70 JOBSITE ADDRESS oZ. _.3 Gf i✓44,Q :1N j !OWNER'S NAME �e[i si✓_ OWNER ADDRESS ': j0/C' !TELS4.42 X , TYPE E OR OCCUPANCY TYPE COMMERCIAL°_PRINT EDUCATIONAL EDUCATIONAL , .1 RESIDENTIAL CLEARLY NEW: ,-I RENOVATION:S-.J REPLACEMENT:0 PLANS SUBMITTED: YES•I NO Id APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ; -:.. --- - _ BOOSTER ; ; _.1:.__._•'.. _j;—----t .._.I_. ..M.. :..--, - ' . .- I _.._.JI. `..._-, CONVERSION BURNER i i`. �_i ._. !_..�.—#.-... . ;..._ a i ! .._..__ --_...J1 _..... i- i...___ J l. _.J -...1 COOK STOVE I _ I r, .... r,J .j, ...-_:�. I_.e .1._.. '-.-:_,1 w ..,_..:..1i.._.,_w t.. . ..€, i. . i... --I• -�- I;..< _.I DIRECT VENT HEATER �_ . + � s. '.--.-_..-I DRYER i•: • I. m.. i ... __I 11 o. ;' I w.,..„I FIREPLACE Y - 1 ; FRYOLATOR 1 1 --I + FURNACE i s �I:i.., . ' I' i; • ` ... a ...- GENERATOR . ._..:. II ... ... GRILLE L_ ... , �. , I INFRARED HEATER • ..,,-s. .1 _.I „•--I,-. ., I ` LABORATORY COCKS a..,w:..,,1 ---=:__,......_1 ._n-_,i,K,..., _--.I.. - . ...---- .. 3. I„t , _s MAKEUP AIR UNIT +� „ .t` —_� J:_ - , OVEN r•.,. I . _...i ....I ._.___I' '1.._ _I,.sa_;_I _ I .._ _.. i z ! POOL HEATER 1.-____1._ji I_. .,, } I-�-�=; ':._.s � t 1 ROOM I SPACE HEATER , 1; I _....,_._f --•�-I:--• f__._.'LI, I s ,....—!..____1* \ ROOF TOP UNIT I~ t.. _ .I i.._ i INI TEST i i: . - 1,_ I I ______I . I_ L. -"--I I I� ,..._.# -._ -_V- ` _ UNVENTED ROOM HEATER • i ! . .# I --L `� WATER HEATER ; ... ....-- .a. OTHER/ .I= ;: €:.. L:(1 #l' . I _. __I.__ ..,I ______I. J I 1 _ .. .I ..__1 _. . ...,.... �. .... ._-.}.___.#�.__L - ' . I,- I..,. .....fi._....._�.1 -_._1.. �_1 .,_____ -_w _. .t_. _ _(._..__,..I.. _,I ___ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES l/NO _..E I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ,, _1 OTHER TYPE INDEMNITY ..,„1 BOND E:-1 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 ._j AGENT ;..J 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 com 9'-nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / /-d4f-e--1 - ... ' / PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE#'12298 '1 . . ... . .. •• SIGNA RE MP•-.4 MGF._„_S JP Li JGF;,,,j LPG' _LI CORPORATION +}#,3281C I PARTNERSHIP..�.f# I LCs#. 1 COMPANY NAME E F WINSLOW PLUMBING&HEATING I ADDRESS/8 REARDON CIRCLE CITY SOUTH YARMOUTH r STATE MA ZIP 02664TEL 508 394 7778 _ f / /-k FAX'.508 394 8256 I CELL N/A IEMAIL accountspayable@efwinslow.com aw � �{� p,r i 174f. 4f i'�t 7 .:j',to Cif c''Wi.i � ,l , n1J'gCrLG'2g Jt��A 0 J7 flLl V nrt erce CCompez'ieatl©n IIIISV1L' LMO A =allawfit:Benldereo/C°G9fultrezeteng 1•leetLneinii I lu mbeTfs jabcstmt Inforrlsnn ncmi Phase Print.Legg R • me(Business/Organization/Individual): E.,c•titi I A5 C ow Q[V,nhio ietet L e,OL\ Q.3 l(tit r, 'dress: r�S 'L e irtA-Q.- ty/State/Zip: Soa csjin 6`IP Phone#: '50S-3cN -1T1Si • you an employer?Check the appropriate box: Type of project(required): rI am a employer with `70 4. ❑ I am a general contractor and I r 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.1 7. ❑Remodeling 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 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' 13.0 Other comp.insurance required.] applicant that checks boic#1 must also fill out the section below showing their workers'compensation policy information. neowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'factors that check this box must attached an additional sheet showing the name of the sub-contractors:aad their workers'comp.policy information. t an employer Malls providing workers'cotpensation insurance for my employees Below "thepolicy and job site 1 rmdtion. ranee Company Name: Art(1)••,-} C^k\-) la-A f(RCA,el CQ., Celr"d �---) • cy#or Self-ins,Lic.#: \ al A' Expiration Date: c—] apt-) SiteAddress:D.1 G Mail a-t' '-i1-41 Ce41\k.Or III City/State/Zip: O 4 67 ach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). . ure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a 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 -p to$250.00 a da against the violator. Be advised t at a copy of this statement may be forwarded to the Office of estigations o the DIA for insurat�efl overage veri cajton. r hereby cert0 tars e e.airs anapenalties of pe jury that the information provided above is true and correct. net& • (.."4r Date: (o1-131 ) adk b" me#: .c1) •3"i`.'ir77?b' 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#: