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Home My WebLink AboutBLDP&G-20-006117 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK eftW—- 1._` i = CITY ��f •.9A� i,l �'�n MA DATE j/1._,/ Z( ._.__. PERMIT#/A�'�/)- 'C 4'I� OBSITE ADDRESS tL_ '.VI 'Vlit L GISll OWNERS NAME �U �1t ` _, I_I . , ,c __ - _.. P � � !1 ERDDRESS . ._._ ��GiC'p�� _�.._._..._ _...-.. ... _., TEL` 0`�`z� �L�%� � FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ri EDUC TIONAL 0 RESIDENTIAL(- — PRINT CLEARLY NEW:El RENOVATION:Li REPLACEMENT: PLANS SUBMITTED: YES F1 NOLI FIXTURES 7 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB L i 'I i 1 `L 'L-�.-- r� - — 1I --- � - 1-1 CROSS CONNECTION DEVICE r.- ( - i t I lit r i DEDICATED SPECIAL WASTE SYSTEM I - I I I I 1_ -1. 1 - 1 r - 4 [ r DEDICATED GAS/OIL/SAND SYSTEM Il � ..... ..tL�.-r --I.._. I EC 1r. ®,I r_... r -r—_ �� I— L_ !L. I__ L_ ---r-- __i --I r-- L f DEDICATED GREASE SYSTEM 1 DEDICATED GRAY WATER SYSTEM I.,_-_trnL ._„, ., _.,4r.�-�I- Ii. #L . ,r 1 -II.- I _.,.._1rr 1L.._ DEDICATED WATER RECYCLE SYSTEM I ;I .11� iI _ ! ,_ DISHWASHER i _--�- ,r —�._sr -i - ) _ _L_--_1---r -_-r --r-- r 1-- DRINKING FOUNTAIN r__..__.-f------I I- FOOD DISPOSER -_r-_ ( -__ r -r r r I -1---- r M . I- FLOOR/AREA DRAIN r - r_ _ I ....__r .-- -;�-- - ._I , I -- I ---1 _ I_ (, �_._ INTERCEPTOR(INTERIOR) I- i'L - -;I---- I r.- ir+- ir, - �. _ r-- -_-'r� ir� yIH �- :r KITCHEN SINK 1 Ili--.r- F---± , - _IL_ _1 H_„ - . �_ _ r (., A _. f f --- LAVATORY 1 ' •I SI . -. � L.��.,1,,.--,.. C-,,, iL:..r-1L:. I ,11___: .;- -- 'r ROOF DRAIN _ ' -II II I _ 11_ .I. °I _ __-r 'I_ '' 'C iL SHOWER STALL I.,. iI II .:I-- [-I _ _ _I__, i - . 'I / 1 __I_-. 'I. ..._#� `.SERVICE/MOP SINK rT_'r__ _ 'rL~ F-11-- fir-- _,17-1--__1--7-II__ : =L_.. -_._'r , _, PDILET C C_ __ :1 -�I� _[1L _ 1I :[7.---1. ---I [. C . .w ' a. URINAL __ 'r_--11 . .± . . .__ 1--_ _=—:I, �_ r�---I[ H _ -- L i . v� WASHING MACHINE CONNECTION L... :;�.... ,- `[ _T T. JL_ __JI__ L ._. 1 1.__ . JI i_ M,_JL-' -`. WATER HEATER ALL TYPES _.L -__,,. -` ,I Y, 'I I II _ ` , .. 1... 1- 'L.. .=I. � L_ ..__ WATER PIPING _I-- r-_�_r._-__r 1-------1-------r .-1-----:- r_ _ _r_ r,.._e—r __._ -- _,�.__ r.._ .-7 _w-- OTHER L ,_.„..� e .. s _,..- I P I ( -1 I I r r I r I r �-F. I_ I ,3_ � � � �� r__ r r - r �IT - I- r i :1--_ r Ir INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES pi NO r- IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY f i i OTHER TYPE OF INDEMNITY Eld BOND Pi 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 [ ,i AGENT EI 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 corn ha with II ertine proyisioryof the 1.-_-_-.) Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `,,,--- PLUMBER'S NAME[STEPHEN WINSLOW — JLICENSE#112298 J SIGNATURE .. N^ _.,1 MP(T JP CORPORATIONHI#13281C 1PARTNERSHIPL #1 I � LLC _#1_ _ j 1 C'!`r COMPANY NAMELE.F.WINSLOW PLUMBING&HEATING j ADDRESS(8 REARDON CIRCLE E STATE MA ZIP 02664 TEL 1508-394-7778 -4 (4 CITY SOUTH YARMOUTH ', EMAIL INSPECTIONS@EFWINSLOW.COM 4- FAX 508-394-8256 CELL NIA R I+ The Commonwealth of Massachusetts Department of Industrial Accidents 1� Office of Investigations i Lafayette City Center . w 2 Avenue de Lafayette,Boston,MA 02111-1750 ,4`1e 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): 1.0 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 10.0 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#I. 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 imprisomnent, 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 ' i the ins and penalties of perjury that the information provided above is true and correct. Signature: . ,,...4.ZAh 01/02/2020 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): 1.0Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia g. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ., ':�l CITY ,___ )' 41 1 MA DATE_ilk/ ZG� I PERMIT# /I -et,Oil )BSITE ADDRESS ',/t�i i?� a J �', r I r�, OWNER'S NAME ',ti, I h i' onC .':-'�? 1 rvt,; I�I n - _ G ' NERADDRESS exi,rp,. TEFAXL.:.==.=.1 TYPE OR OCCUPANCY TYPE COMMERCIAL[' EDUCATIONAL u RESIDENTIAL Li / PRINT CLEARLY NEW:Lj RENOVATION:0 REPLACEMENT:Pr. -- PLANS SUBMITTED: YESLJ NOLJ APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER [__ 17 -_1--_---I._._.."I `-_`L.._ r 11-h_I1„_ -1- I_...._!ETC_ BOOSTER r...._u.. 1. , I- L 1.._, • ...,, l_ __a L._ . y I-- L I._ 1. r....- I CONVERSION BURNER - _' . L I.� ( . I i I I I i I I - La,� COOK STOVE I. I-.__I._ m LLL,..1_,_7___I__. ..I 1.-*__::. 1 , L _ LL L___1. ,.-_L__.. DIRECT VENT HEATER r,._ I_ I„�_, �( 1 I. , __ I_ In.- _;I ....._1 E ..J�.. !: ...��....__�L._ .._T._,_.: DRYER L 'I_ _ Lm..�1 ._. - - - FIREPLACE 1 '1 aILL�..�'� 1r- -1 !(_-.�__T_ ...-� 7-11: IL.., .. L 1- !�. ,I -_. .._-FRYOLATOR -- ----- —i� -_1 `I-- I I _L --.^; --�if- 4 L—II _n I . ice`�,_. FURNACE r. I ___ '- ;I___—_I �_i11-- - . eh_ 1_ ._. 'I - iI_._,iL.- 1E7 J GENERATOR I. -_r- I 1------1 1 --_ I I ._- I.___._ I___ .,'I 1,_ .;I-_____ l_- GRILLE I _.L L---L�.__.-,I ..ram I._ 1-- - 1----- I-___ r-- 1_._ I___ 1.1,�.. • INFRARED HEATER - __ - LABORATORY COCKS L I ____I- .�,I- I --I- - - 1 • -I - 1 !- 1�_. 1_ -.,I ---,A_____„: MAKEUP AIR UNIT -v C_ I[ - -1i 1 i 11�.�,T __:11 J 1.1_11- i _.. 1 �.,. fa ' _3[7.7. OVEN - I --i1 .� 1 I1�......!1 I __.if.aiC I,L..�kI II-__.i� .!: -=. POOL HEATER I II . �ll_.___`� II �;1 -..,ir ---r- 1[.�,_�. =l _r 11 _�i ROOM I SPACE HEATER _I--_I. __I E-1_..__I. ___i I ', 'L____.I L_ 1 r ... 1� LI I I r ROOF TOP UNIT E— 1 - ' - -11-1 _ .�, I I L I r J r�.es r�...._J TEST L,a_ - _ L_ _� r :I- .i I_... I s,i .. UNIT HEATER L .iI h... _ I___ I I _I ,I _::,r 1 tr�w (~ C-71=C UNVENTED ROOM HEATER r.. -. 'r . . 1----r ,(---_-_ r__-I -:ru-` .a.'1---.r :2 r...�.1 w, L. , WATER HEATER I I� 1_-_-_,-L I J l I :1 L�-1 L.,- (.. r_.� 1. . : I_-s L�:� 1__..T I_- r_ T:is .::L_-_- I______: [�.�:l"_ ...,v_ L- ;-. c OTHER _ _'1_ �I _" ;gib . .:.,_ .,.. _ I _-1_ (--_ i -_ I_ I- I I :,.., ! . : I 1 ^I 1 I- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES EJ NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El, OTHER TYPE INDEMNITY rL-:; BOND El 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 El 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 and Recut—to th-e-kr stof-my knowledge -- �S, and that all plumbing work and installations performed under the permit issued for this application will be in complianncc i a YP rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r L!/it • !/ nr, PLUMBER-GASFITTER NAME[STEPHEN WINSLOW LICENSE# 12298 SIGNATURE r-- i,r MP El MGF® JP 0 JGF D LPGI 0 CORPORATIONI i PI3281C PARTNERSHIP EP I LLC #= '. .� COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE " `f' CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 0 508 394 8256 CELL N/A FAXEMAIL INSPECTIONS@EFWINSLOW.COM at+ s The Commonwealth of Massachusetts _ f Department of Industrial Accidents =°y Office of Investigations �p 1 - Lafayette City Center 7. =��y= 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. T- I-am a employer with 9.9 __ _..__.._y.., employees.(full aricU 5—.. Retail-- ' or part-time).* 6. L]Restaurant/Bar/Eating Establishment 2.0 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. 0 Non-profit 3.0 We are a corporation and its officers have exercised 9. []Entertainment their right of exemption per c. 152,§1(4),and we have no employees. [No workers' comp.insurance required]** 10.❑Manufacturing 4.ElWe are a non-profit organization,staffed by Volunteers, 11.0 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: 11 Policy#or Self ins.Lic.#1909A 01/01/2021 ! Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). I Failure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up o$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 he DIA for insurance coverage verification. do hereby cer ' e the ins and penalties of perjury that the information provided above is true and correct. I ignature: T Y '' �(/ Date: 01/02/2020 lone#: 508- 94-7778 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): I.OBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.OLicensing Board i.0 Selectmen's Office 6.[]Other :ontact Person: Phone#: