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Home My WebLink AboutBLDP&G-20-001283 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK tom'2g ' CITY i/�/1 7�?y .._a�,___ MA DATE17.3 /, PERMIT#. P02c 0"o �`.t JOBSITE ADDRESS 7 dima4,, j„/ /t fi'j( 1 OWNER'S NAMEIt L/ c _, fflJdlL Svc. POWNER ADDRESS 5e,e C._.,, ,, . _ y. _, , ; TELL. c -,71 .1,,E d FAX TYPE OR OCCUPANCY TYPE COMMERCIAL'_ I EDUCATIONAL __;. RESIDENTIALIft PRINT v� CLEARLY NEW: RENOVATION: 1 REPLACEMENT: PLANS SUBMITTED: YES 1_..j NOL FIXTURES 7 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 _,_ i I CROSS CONNECTION DEVICE l DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM 1 ii r DEDICATED GREASE SYSTEM i J. DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _ ".. i FLOOR/AREA DRAIN .. INTERCEPTOR(INTERIOR) ) KITCHEN SINK LAVATORY zl ROOF DRAIN --�` ..... SHOWER STALL ....__ SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES WATER PIPING OTHER a fit , 4 d INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 1 NO , j IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' OTHER TYPE OF 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 ri AGENT `s SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are try 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 S• nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ 'tea .�:ic�,�.: _'___ SIG ATURE PLUMBER'S NAME<STEPHEN A.WINSLOW .__LICENSE#i 12298 r` " MPLJ JP[J CORPORATION#E3281C PARTNERSHIPI �#1 J LLC. COMPANY NAME`, E F WINSLOW PLUMBING&HEATING i ADDRESS I 8 REARDON CIRCLE _,,;:, CITY[SOUTH YARMOUTH ;STATE I MA ' ZIP `02664 I TEL 508-394 7778 L._ FAX 1508-394-8256 1 CELL i NIA EMAIL ACCOUNTSPAYABLE a(�EFWINSLOW.COM The Commonwealth of Massachusetts =r 1-ft Department of Industrial Accidents 2,1ietilSZ _= 1 Congress Street, Suite 100 °`�— • Boston,MA 02114-2017 '11*-- www.mass.gov/dia 'Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Leeibly 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 Arc you an employer?Check the appropriate box: Type of project(required): t.0 I am a employer with 88 employees(full and/or part-time).* 7. New construction 2.0[am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 30 i am a homeowner doing all work myself.[No workers'comp.insurance required.] 10 Ei Building addition 4.0 i am a homeowner and will he hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole MO.O Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.171 i am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,*1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#t 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. lithe 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 it or Self-ins.Lic.4:1909A Expiration Datc: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 und e pai sitnd pen !ties of perjury that the information provider!above is true and correct Signature: Jt/^-t /_.._a� 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 WV CITY I,"a.5._-7-- ii_g it"A r_g_i-2/ . _:1 MA DATE_2 /..2.. PERMIT#&—R9-010-60/2; JOBSITE ADDRESS ..7.,, _ itimi AA-j ,,f._Raj ', OWNER'S NAME GOWNER ADDRESS • .. . . ___,-TEL 5J.1!_Z7-517FAX TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL 0 RESIDENTIALX PRINT CLEARLY NEE 0 RENOVATION:L:1 REPLACEMENT:p7,4 PLANS SUBMITTED: YES': NOEJ 'APPLIANCES I- FLOORS-+ Emma 2 3 4 5 6 7 8 9 10 11 12 I 13 14 BOILER IIIIIIM Mg_ _ 1_ .11 ._17.7117.71171].._, i _ _.1,._ . __1_ : BOOSTER WIMMIIIINIMFMIIIMJL_ . El_.._ Ell= ._. _._ =LW CONVERSION BURNER 11___I r 101111177.1 ._ . JI____11 _,_ .1[77.1 _IMMO 11*.= _ _IMIIIRMIWWILIN DIRECT VENT HEATER uttmeimaimuminwpiiitaugioupisp-Num - - DRYER• • - • • • • • -IMMEMIMI III_MIKIMI: imilluml. --,1.- 'M FIREPLACE IMIIIIMIIIIM 'W-I-11.1MW ...-77111_11Min. .2 i FRYOLATOR :---- -i MANN MininilIMOMIIMIWI Min- WM FURNACE = __. .___ .r GENERATOR. ION1 GRILLE 1-_-.73nm ' .. mmujitil.LM .MJ ' E. INFRARED HEATER ririniiiiiiiiiiiimmononsOmMMIN LABORATORY COCKS NM IIIIMMONUNIIIIMMW LAIIIIIIIMIMMMIE MAKEUP AIR UNIT MINA woMMINWPWRIMNIMIMNININIIIIMAIMI • OVEN MMWMINIIMIIMMIIMIMMIMIMMOM POOL HEATER MFMMINOMMNIMICIMMIINIIMMMIMMIM ROOM/SPACE HEATER 11011.MMINIMNIM1ILEM1111110110111111MMINSI Ln - ------ --RDDETOP-UNIT---------------— ---.i MOIMINIMIEsMMIONIIMITIMMIMS___ _._ eN TEST lsmilmitimeMMMIIIIIMEMIIIIrli UNIT HEATER' WWWIMIMMIM___ MilligMll IM_M NNW NJ. UNVENTED ROOM HEATER F-M2IMMI ENIMMINIMilimilM1 MNIMIWIIIIM WATER HEATER MMIIMNKMLMMINMIIMIMIM . ,mr-ww OTHER - -111.1MMINITT--IMNOIMM11.11MI 111_11MIM 7,1 . ...__ 1. _JINIIMIANNIII illitiMMIMIIIMMIEll -- ___ __MWONIENIMMIIIIIIININIMMIlltsgML. _11 [ . Amultniwar-i-.-AmmmiNMINNIIIIIIMININITIM 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 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE INDEMNITY El 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 Genefal Laws,and that my signature on this permit application waives this requirement, ' • CHECK ONE ONLY: OWNER 0 AGENT Li 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 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 It nce with all Pertinent provision of the • :Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' ai, .1(24.4Gdjeg-4— PLUMBER-GASF1TTER NAME STEPHEN A.WINSLOW .... „_._ .LICENSE# 12.29B 4 I' r - Sf G ATURE MP El MGF 0 JP 0 JGF 0 LPGIO CORPORATION 0# paip.___ . PARTNERsHIPO#1 ,. _ .1 LLC d_ ._,_ _ . COMPANY NAME:Iff VV1NSLOW PLUMBING 4 HEATING ..,ADDRESS 8 13cMDON CIRCLE _ . . CITY PIJ.1. _Y,A.M9111FI . _._____.______, STATE[I*.,14T MO. ..,..TEL,5907394-7.7... __... ____ FAX 08-3.94-825P I CELL N/A .. ._ EMAIL appoyntspayable@efw109w.cpm . _ .. .. . . LP 8-- . . . . ______ The Commonwealth of Massachusetts Department of Industrial Accidents 1 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.❑✓ I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction 2.❑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 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑ Building addition 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. p ❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 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. 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 a pai s nd pen lties 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#: