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HomeMy WebLinkAboutBLDP&G-20-01602 \` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t,..= .'-iff,) CITY __.yG✓rNoL�'�► _ _____ q MA DATE 'I�{Ii q . PERMIT# /07-Q�- 00 60)---- JOBSITE ADDRESS 35 .0.1,1_CAS& R1.S twa OWNER'S NAMELv_S_Ail._._ 1,�3n.eai ____._.___I P OWNER ADDRESS 13315IopEciak Dr, pc sim,v (, ?b ( TEL 413 Pig 341 ,FAX __I TYPE OR OCCUPANCY TYPE COMMERCIAL[_l EDUCATIONALI D RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NOD FIXTURES 1 FLOOR—). BSM 1 2 3 I 4 5 6 7 8 9 19 11 12 13 14 BATHTUB _ j `— - CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ' ! DEDICATED GAS/OIL/SAND SYSTEM 1 _ __ i__ _._1 i DEDICATED GREASE SYSTEM ____ DEDICATED GRAY WATER SYSTEM 1 DEDICATED WATER RECYCLE SYSTEM T _ DRINKING FOUNTAIN _ - - _.._ _ _ DISHWASHER--_._ - - -- FOOD DISPOSER I--___ I-- I I__ FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) -_ 1 --_--- KITCHEN SINK - _ ial r LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK __ - I _ , TOILET URINAL WASHING MACHINE CONNECTIONIan �_. ®_- WATER HEATER ALL TYPES WATER PIPING ;____- IMIIIII OTHER - - Qim— _ r O INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO 0 rt IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW Itrp LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 BOND 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 tr -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 ciance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� 6°�J PLUMBER'S NAME!STEPHEN A.WINSLOWLICENSE# 12298 ` `— _____.....___- _ _ SIGNATURE MPD JPO CORPORATIOND# 3281C __ PARTNERSHIP©# 1LLCO#4_____.__-_____ COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY`SOUTH YARMOUTH __ STATE 1 MA I ZIP 02664 _ -^_- TEL 508-3 94-7778___ _ T 1 FAX 508-394-8256 j CELLI N/A I EMAIL I accounts payable efwinslow.com The Commonwealth of Massachusetts 1, Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.gov/dia \Yorkers' 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 2.1:I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 Building addition 4.EI 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.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.ID 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 s nd pen !ties of perjury that the information provided above is true and correct. Signature: r °~_ _ 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#: Ea MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK , `E `. i� CITY MO _,. ..._. ....._: MA DATE_9_p._fic{.. _ PERMIT#6320f — I /C ) ..— JOBSITE ADDRESS I3 ..(2I . - st4, Qa:V4sait,.4 NER'SNAME,SvSaji.. lAJiL(iIX r:._._._._-- GOWNER ADDRESS Ls is_.B okkat_.Dr._. ALT,6. k.j__I TEL Yl e� if 09/..IFAX-------_ __.. TYPE OR " tSa4l PRINT OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL Q RESIDENTIAL 2--- CLEARLY NEW:D RENOVATION:El REPLACEMENT:Er PLANS SUBMITTED: YES[] NOD APPLIANCES 7. FLOORS--I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER IIIIMi 1IMNMBMMMMIMMIW��._ itiMI-- ' ----�, BOOSTER MM IMMI®�®�MI_.. I - -. 1 ® CONVERSION BURNER MI �[� __-._.. . . .I . I _ ( ._ -.._.. � �-II COOK STOVE 11111MME li. _ I_ . .._Ma Wil _,-__. MTh_L___ DIRECT VENT HEATER ®I.._.__ ___._, -,__L(._V 1 1 DRYER . - M _mom IM—®._M(H f FIREPLACE MA®MM MM® ME® ____= FRYOLATOR M M MN SA -�lMi®®�MIN®.. .._: FURNACE -rTI--L ..._I,_. ( 11-- .I IJ-- -1� GENERATORI . ._ I..... .I j ..__..1.._.. — ..-^I GRILLE ilmwati MI® _.Hall .....__.maim .. �i ...- I , _- oll COCKS ��� C— L , �� INFRARED LABORATORYHE COCKSTER _il__Lirtism I.. ®��_____._. _ MUM MAKEUP AIR UNIT ®�®�M®-M1�I��I�®®M® OVEN -® JPOOL HEATERmant...716m1 . .I _ :I _. .- ROOM/SPACE HEATER® .j �is®(.-- ..;I!__,_ ;I ' - --• -ffirig.F=MEMENIEIMift NE e!!!!imml[m_JIMI JL. __11-1 UNIT HEATER _�__JIwi_!MIM MFM� �®] ' MU UNVENTED ROOM HEATER _ �®®�NIMIL®®®®I®MWIIIM WATER HEATER — MMIMMIM ®MM�h'_WW! O OTHER[ .. .--I®IM®®I...-.._..IM®EM®®®(M®IM `o _. _..__.._ ICE®®®®®®� MI.... L..._I INSURANCE COVERAGE vJ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY .+' 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 0 AGENT - 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: nd 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.r ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME STEPHEN A.maw , LICENSE# 1 2298. _ SIG TURF MP D MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION D# 3281 C_- PARTNERSHIP 0# _. : LLC D#_ -,,._ _. COMPANY NAME:I EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH . .. ._ -__..____. _„ _ ; STATE LMA .-ZIP 02664_ , TEL 591994-7778. . . . FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com The Commonwealth of Massachusetts LIV�_ L Department of Industrial Accidents �''-`` 1s 1 Congress Street, Suite 100 , �'1 Boston, MA 02114-2017 W www mass. ov/dia 5" g 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. ❑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. 0 Demolition 10 Q Building addition 4.❑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.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. p ❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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 a pai s yend pen Ides of perjury that the information provided above is true and correct. ®Signature: r '°-� /�_ 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#: