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Home My WebLink AboutBLDP&G-21-000049 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK MI CITY YLVAIQJn °" MA DATE �.1Iff =.= _ _____._._.__ __ (f �l CZIl n PERMIT# /Il l�/)a'Zr-CXK'f1 JOBSITE ADDRESS 6 wi[I)1t pwe(-,'i _ J Votoblpuhf poi_ OWNER'S] NAME Pei fe_ F(G�ict5 POWNER ADDRESS mt _—_ _— TEL 23.1 2 11 Z i 5 i FAX __ __. ___ TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL 0 RESIDENTIAL I PRINT CLEARLY NEW:Li RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO0 FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB L i ; _ ' w,.r 21- . 17 , _Y I-7__ l CROSS CONNECTION DEVICE L I_, . I I ' _ _; � , _E__.(L 0 DEDICATED SPECIAL WASTE SYSTEM 7__ f( __ tI _K'I __.._.wi __. ::3_t 'L.: i - -E .L.77.1 __,. 1,L ._ DEDICATED GAS/OIL/SAND SYSTEM I [�- _ ' _ •_ J {L. DEDICATED GREASE SYSTEM _ '... ,- _� 1, 1 -_ .I_ _ ;L_,�.. _ L____, DEDICATED GRAY WATER SYSTEM I }_ I _ , L__. ,wri.,___L__� I L�= DEDICATED WATER RECYCLE SYSTEM ,i L . I + _L I - ;IL I DISHWASHER DRINKING FOUNTAIN �� lam I .__iL . l L__._...JL.___ _I it 'I___ ._, FOOD DISPOSER i FLOOR/AREA DRAIN I =Ei _.,_,_ ;s I I r ;� I INTERCEPTOR(INTERIOR) ( — _ { ss' KITCHEN SINK I v � _ �� LAVATORY [.. _ __ 3 ROOF DRAIN I is SHOWER STALL �---�� SERVICE/MOP SINK faliNIMENIE �MltllIIIIIIIlNS Min ino TOILET r i _ , URINAL lans...a...,WASHING MACHINE CONNECTION r — WATER HEATER ALL TYPES i _[ r .;WATER PIPING )� �— [� i sI OTHER I iF L [77] ,rii[ I nr . _. _T._. � - _ I-��7'[ . . :ram` 4IL. rA v�. - INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ril NO [1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I i I OTHER TYPE OF INDEMNITY [11 BOND ri 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. �i_) CHECK ONE ONLY: OWNER fl I 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 true r e to the b t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com lia with ll ertine proyrisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r ,., t-- , J PLUMBER'S NAME STEPHEN WINSLOW � _ LICENSE#J 12298 J SIGNATURE 0,-...... . - oo MP[' JP CORPORATION17]# 3281C PARTNERSHIPM# LLC # COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM /-J /i L.y ,�U 7 The Commonwealth of Massachusetts Department of Industrial Accidents f. Office of Investigations _A 1j. � =a., Lafayette City Center l° 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 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: Business Type(required): 1.❑■ I am a employer with 90 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. #1909A Expiration Date:01/01/2021 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under §25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' of the ins and penalties of perjury that the information provided above is true and correct. ,¢/ 01/02/2020 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(check one): 10Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia �; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORKpia•_ _ % o=•-�,.• CITY 1 IYIIYI MA DATE� (t74 _ PERMIT# /?�0/)-6//-OW0V1 %;.—y JOBSITE ADDRESS/ ( fin Yit,(n ,I h 1 OWNER'S NAME I _ 19991 c fri nhrS GOWNER ADDRESS ' yt1VPie TELL 1_11 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL I_ ' EDUCATIONAL I. RESIDENTIAL I -PRINT CLEARLY NEW:[I- RENOVATION: - REPLACEMENT:ler PLANS SUBMITTED: YES I, NOL APPLIANCES Z FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER __.. BOOSTER CONVERSION BURNER COOK STOVE - - ,- DIRECT VENT HEATER DRYER I I I I FIREPLACE , FRYOLATOR , FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER _ ROOF TOP UNIT , TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER.: 1 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 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LE OTHER TYPE INDEMNITY 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 " .,; AGENT (— SIGNATURE OF OWNER OR AGENT J I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the b st of my knowledge cp and that all plumbing work and installations performed under the permit issued for this application will be in complianc I n PPrtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.Itt ` !/ PLUMBER-GASFITTER NAME[ TEPHEN WINSLOW 1 LICENSE# 12298 J SIGNATURE r ... MP� MGF I-_,.. JP Li JGF D LPGI 7 CORPORATION l7#II 3281C ___1,PARTNERSHIP T'#I 1 LLC�Q# $_ __ ? tp COMPANY NAME:I E.F.WINSLOW PLUMBING&HEATING j ADDRESS'8 REARDON CIRCLE N 1/4)- CITY {{SOUTH YARMOUTH STATE MA !!ZIP 02664 TEL 508-398-7778 ___1 FAX 1508-394-8256 CELL[N/A !EMAILI INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts M Department of Industrial Accidents 9—_� Office of Investigations �e.�� Lafayette Center s�__n1_,YCity jr 2 Avenue de Lafayette, Boston,MA 02111-1750 .i"' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 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: Business Type(required): 1.❑■ I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. [No workers' comp.insurance required]** 11.[ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. #1909A Expiration Date:01/01/2021 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. . I do hereby cer(iA}-een ee f the ins and penalties of perjury that the information provided above is true and correct. Signature: CM)I""` 1�� 'E'�--�. Date: 01/02/2020 g 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(check one): 1.0Board of Health 2.1=1 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.['Other , Contact Person: Phone#: www.mass.gov/dia