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HomeMy WebLinkAboutBLDP&G-20-002359 r------' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK a--r-- _-_-' CITY . C ULI __ Lci . MA DATE Z PERMIT#AL/ '' `,/ ' JOBSITE ADDRESS 141 .5 e f_ _ el__T ) OWNER'S NAME G4- 6 _L.I_L(._._T.__I POWNER ADDRESS 'J! ,'_(/i r',/' LL''� 'f'11 TEL /f'.,3-2 05 // I FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL 3� PRINT ® EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:J' PLANS SUBMITTED: YESD NOD FIXTURES 1 FLOOR—} BSM 1 2 3 4 5 6 7 8 9 18 11 12 13 14 BATHTUB _ _ IIIII AMMN NMIMO MIN CROSS CONNECTION DEVICE MILIIIIIIIMErmilli maw infiffigmtm pap RE ma DEDICATED SPECIAL WASTE SYSTEM in Mai in 111111111111111111111.1111EXICINIIIIR a 1111"II DEDICATED • •SYSTEM al in NM MEIN.in 11•11 EP MIIIIIIIIIIr DEDICATED N. .,au ______ __ - i II -- - DISHWASHER M-1.1151®®gam- 1DRINKING FOUNTAIN Mill 1011,11111-11. �� 11.1,®I®1111[ INTERCEPTOR T M.MMN I �I®( INTERCEPTOR INTERIOR) ® �� MO NIIIIM KITCHEN SINK _ - ,Eell --aliall MRkillOOMANIIIIIIIIIIII LAVATORY ROOF DRAIN ---- �--. ;v M .MMrSr�r M mom umumum:mu Ems®®®NEr®all,®NMI NMI SHOWER STALL ;�'®O;®��r®E—1 r�®�;®NMI SERVICE/MOP SINK ®®® UMMu um Mimi imilm rm'61 18000 TOILET ME®MN1.I.IMIIIMEEN®ME1101I_:m1 WASHING MACHINE WATER HEATER ALL TYPES CONNECTION ®®EMI WHIM!NM 11111111.11111_____ ME®®;N OTHER 11111111.1111101111111111111111111111.1111111 Ell MIN IIIII NE MIII MN MI Mik NENE NM Mil UM UM IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIINIIIMII Mall ME OM Oa ME AM MIN 101111 RIM MN ME 11111 111111 Mell INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0 Q 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 AGEN T ^' SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are ue 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 co pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / / PLUMBER'S NAME STEPHEN A.WINSLOW - LICENSE#1 12298 SIGNATURE ,� MPO JP® CORPORATION0# 3281C PARTNERSHIP©# JLLCO#1 _ ,u1 IAD COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE _ T .____._____,�' CITY)SOUTH YARMOUTH STATE _ MA ZIP 02664 TEL 508-394-7778. _ ___I FAX 508-394-8256 CELL N/A EMAIL accountspayable efwinslow.com qv 1,, Lf2, The Commonwealth of Massachusetts ► � 1, Department of Industrial Accidents W w 1 Congress Street,Suite 100 Boston,MA 02114-2017 o„M=yve 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. 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.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑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.❑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. 13.0hoof 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.['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. lain 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: 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#: r— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK E— i CITY y_af- W IL �w .50 - MA DATE I1 PERMIT#/, -D/ ' , ' JOBSITE ADDRESS -`„]_.5i7�'16�./.._ jg447-1 .._ OWNER'S NAME e.g.., -.: EL. _.......-.1 G OWNER ADDRESS ._I .fp,C> Citf 1.61-44iJ�gPA TEL�l�_ Z .� .D`�/.FAX)___.__._..__..I TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:[ RENOVATION:0 REPLACEMENT:L PLANS SUBMITTED: YES0 NO[ APBOILER NCES 7� FLOORS-� eL�l_1--''?_ _.3._._I I_.4 5 8 7 8 9 10 11 12 I l_ 14 - ..__l BOOSTER MIW 1®mmell .__..___LO� -- CONVERSION BURNER ®��®®M®1®I_II __I1l �® - -- 1 COOK STOVE _..---I--....--.i._- -..I ®'----_.I .:.._i. - 1-=__I......_I DIRECT VENT HEATER —_.-'II I. ...-I I ® 77I---..-.I _ F -=11-----1 - -. . . ......1I -._.I _.-_'I®_..._._�I®I®IMlI®1.-__L I�� CI DRYER FIREPLACE 1----_'''�- . ._. I,...._1I.......1..._..,iL... .. .. ._ _ .. ---J FRYOLATOR .111 _ :1 - iI-. ._J _ .... .. _..I. II--. _II - - . . ._..I� FURNACE -- ...-.. . . . . .. I—� . _ ..I—�1—il I GENERATOR, I �l�® -.�_-. . -_-- [. GRILLE L I I®I®®LI�®�IMIII INFRARED HEATER MIMURNMILINIM MIU INEM MN®I _ _M® LABORATORY MAKEPAIRUNIT M® .--1 — JUN PA - . ® M OVEN 1__. .....-:I .._ J_L. .1L=1 . _ . . _. I POOL HEATER L;__' . ._. TT] ' inr-7-1 . ROOM!SPACE HEATER - ...I ____ - 9 - 17- i l... L- J =___ IM .- _._ -- --ROOF�fOP-tlivt�--------------- .-_.f- I-- -__ MI_ ' ..ILN-- -- . . . ®� ���--- --- TEST Is I... ...: ®�z � UNIT HEATERI I� ®� UNVENTED mi ONI _1 Q WATER HEATER HEATER �I� .. ... � 1�JL J I �� OTHER�— 1 .. ....1L_i... . I. �� __I .. _ -... _..1 ......._1.._ ..:gIII_l®hl®`MIIUIIIIIII'_(_elf ATIN[�.ii ....... L_.,..1O _. . it _I _ . =NNNIIIMMIN INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES i�--� NO 0 `- ) I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY[l BOND Q -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 true "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 compll'-with all Pertinent provision of the :Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME STEPHEN A.WINSLOW .LICENSE# 12298 SIGNATURE va• MP 0 MGF[Q JP 0 JGF Q LPG!Q CORPORATION[l+_# 3281 C PARTNERSHIP 0# . LLC Oft r ._-,,. -, COMPANY NAME: EF WINSLOW PLUMBING&HEATING .ADDRESS 8 REARDON CIRCLE { CITY SOUTH YARMOUTH - _y_ ___ STATE MA 'ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL NIA . EMAIL accountspayable@efwinslow.com The Commonwealth of Massachusetts _t z W 1, Department of Industrial Accidents MAW Department Congress Street, Suite 100 Boston, MA 02114-2017 .,, 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): 1.12 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.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 ❑ 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.❑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. ROOF repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We area 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.Lie. #: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 par s gnd pen Ides of perjury that the information provided above is true and correct. Signature: ? ' r„Q/�_ 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#: