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Home My WebLink AboutBLDP&G-18-006021 b`a C -- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '.e im 11 . CITY! _ _6 ,. . r- J g o -:7'ff MA DATE E y-/3 / PERMIT# �71'�(aG.2/ JOBSITE ADDRESS 0F .y tl sZ,,4 'if,. m_,,:I OWNERS NAME[6.5cp ;.A!�s3sT�n P — _- OWNER ADDRESS [ .S/�/f?t�_ _...._.. -__ _.- - - TELIJCI.366.?.,?s.e. ..EFAX1. TYPE OR OCCUPANCY TYPE COMMERCIAL I,:j EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW:i , RENOVATION:I REPLACEMENT:x PLANS SUBMITTED: YES i NO, I FIXTURES-1 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ' DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET N' URINAL WASHING MACHINE CONNECTION c� WATER HEATER ALL TYPES f — �C WATER PIPING OTHER i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY;i 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 : 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 -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. _.___ --.a ..._...., _„_.,._ _.�.�. �� 1-Y j �!1 f PLUMBER'S NAME I STEPHEN A.WINSLOW LICENSE#112298 SIGNATURE MPx✓ JP J CORPORATION', ,,;#j3281C PARTNERSHIP[j#[ _ ILLC[, # y� ,__.„ COMPANY NAME I-E F WINSLOW ADDRESS{8 REARDON CIRCLE 1 i CITY i SOUTH YARMOUTH I STATE r MA I ZIP 102664 1 TEL,508 394 7778 FAX 1 508 394 8756 I CELL I EMAIL I ACCOUNTSPAYABLE@EFWISNLOW COM zgif ,16 ler '4y-- ep r/�'aei g Of indESiF e3IIICCUIO'BF3) �i 600 W sTdit> � r+ ., �bo �PEY�B Bosgoig,M4 02111 . www 6p2c s. . Workers' Compensation Xmsiarn»nce Affidavit:Buillolelrs/Contrzetoresi ectric3ans/ 'fluaallbeiw A lite2nnt Inon Please Past Legibly . Name(Business/Organization/Individual): E.C•WI Q„.,) Ok),h, (.t,,, a_ 0 ��ce Q„_ 1 vic Address: c5° 0,e1 is CI(cl.r.L. City/StateIZip: Soo�vo ,-T.,r , -(Pc Phone#: '50S- 3 -i'77 . Are you an employer?Check the appropriate box: Type of project(required): ,,NrI am a employer with 70 4. [] I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors :, I am a sole proprietor or partner- listed on the attached sheet.1 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ®Demolition working for me in any capacity. workers'comp.insurance, g• ❑Building addition [No workers'cornp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions I.❑ I am a homeowner doing all work , right of exemption per MGL 11,[]Plumbing repairs or additions myself.[No workers' comp. c, 152,§1(4),and we have no 12,0 Roof repairs insurance required.]t employees.[No workers' 13,111 Other comp.insurance required.] toy 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. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. y km an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1 rormation. tsurance Company Name: .,J " ('"tv C ,pure&el(_g„ Ce7fv.,/R-k✓1 olicy#or Self-ins.Lic.#: r S a) A Expiration Date: —t — au-) ab Site Address:, 3 C+1nMcril w-E'Q-Prh s-Q1 e e:S\ftA I \1 City/State/Zip: C ,)4 (o 7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Cup to$250.00 a dayagainst the violator. Be advised that a copy of this statement may be forwarded to the Office of westigations the DL4'for insurar et overage veri.f a ion. i do hereby certify un e e airs and penalties o pe jug that the information provided above is true and correct. ignatue; (A/A- Date: Q oti_) 3 I .1 ad[g( hone#: ,c)g.3`1`i P '77X 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 = t_:ink_ =;17_, CITY :..S� ry../if y �/. ,T//..,... I MA DATE V 43 "/ i PERMIT#/✓-0�1"�l�Oal . .. JOBSITE ADDRESS ; �.. ........ . .. .............. ... ...... . ..... ........ . ... o,v . f d6' l OWNER'S NAME Jp-s.v, ,,.,,A/z:€3S.17=- ... OWNER ADDRESS S ii • TL ;FAX TYPE OCCUPANCY TYPE COMMERCIAL__I EDUCATIONAL __ RESIDENTIAL')' CLEARLY NEW: II RENOVATION: REPLACEMENT: ,1 PLANS SUBMITTED: YES___vl NO „ APPLIANCES 1 FLOORS—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I: i I BOOSTER .._. ._. _..._-° ..._ .... _....-- - - CONVERSION BURNER ._.._._ _ . ___... µ _.. : ..... c COOK STOVE 1,, j I �n__ I- I _ �! l : i ` DIRECT VENT HEATER .-. , w i E �-- J .__i DRYER ( ( - FRYOLATOR � � i FURNACE � l J _... _.._. _.. GENERATOR GRILLE J I a I INFRARED HEATER ; - k ; LABORATORY COCKSL.—,,,,,,J;„.„,.. I. , ... r:.._M.„yl. �. . ... ` I y:� ... ...__,1, I ,1.. MAKEUP AIR UNIT w j € OVEN ;: iL. ..- ,: -_ _ . . ,.. _.. � �.F ._I I' _.. I I _.. ..-a.J. ..., f POOL HEATER l: I: 1 i. 1 ! I� t fir-. ROOM/SPACE HEATER _ I I 1 I I I' 1 I _ '` I _; \ ROOF TOP UNIT k... .....1-.. >.. 1' ......I:._,.._._...f; __lc- I : I_ .,i . I , ... TEST I I .,. i 1 I1_,.,_._ I ,I 1 ` _ 6\ UNIT HEATER UNVENTED ROOM HEATER .. 1 I; I-_.___..1 i _ J I I I 1. .._..,._1 ._.____I N WATER HEATER I j' I 1._ I .. ...._i._ 4....___.__1 . . _ - i I OTHER._._. ; I: is 1: ..1:_.. . f` I f ____ ;` 1._.._. r .._....._.I . t. 1 I: .1 I:_ I'..._._... I__.._...I. I` .k . l J. t'..„....J__.,- !_uw,u..e.,._ .....„.......1rr-w..... .-_'—_... . .._,J..s._......_... ..._.-- ..rn+__._n. .......,.....1INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I,! NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ,,!',...1 OTHER TYPE INDEMNITY _ BOND IL.) 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 „ „f, AGENT i.....K1 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 complian 'th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE# 12298 4 SIGNATURE MP."! MGF _., JP .1i JGF:L j LPG! w CORPORATION•+, # 3281C i, PARTNERSHIP.,,..# 1 LLC _J#. COMPANY NAME E F WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE R_ CITY SOUTH YARMOUTH STATE MA I ZIP i 02664 TEL'508 394 7778 FAX 508 394 8256 I CELL:N/A !EMAIL' accountspayable a efwinslow.com l LP l/ I Ikp a§°grae'g of Inter iwG' iiecgryems . ,terit ., Office of 2[r wesJigfgions 1411!. l'ff I. , ,�� Bosseon,i 02111 r6,,ui WW✓S9omes&gov/dike' • Workers' Compensation Trust.rrance Affidavit 1B»ildera/ConyractoniElectrcicia, / 'Il abets A 'leant Information _ Please Print Lea Name(Business/Organization/Individual): E i .vv i r,5I ovtl 0v,„,,biv-Ic QL k c -t r`6 0_, 1 i(.o Address: (4c'i rci 0 j City/State/Zip: 'Soo-v\ ter,,,4 i'-Or Phone#: O - 3i9-117 l Are you an employer?Check the appropriate box: Type of project(required): ,,, I am a employer with -70 4. El I am a general contractor and I 6. El New construction employees(full and/or part-time).* have hired the sub-contractors I.❑ I am a sole proprietor or partner- listed on the attached sheet.I 7. El Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition ' working for me in any capacity. workers' comp.insurance. g. Gl Building addition [No workers'comp.insurance 5. El We are a corporation and its 10.0Electrical repairs or additions required.] officers have exercised their i.❑ I am•a homeowner doing all work . right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs . insurance required.]t employees.[No workers' 13.0 Other comp, insurance required.] thy 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. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. lm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1 formation. ` tsurance Company Name: •,,-s �vivOil fl,"LNu,F1 cG V1--) olicy#or Self-ins.Lic.#: `B a I A Expiration Date: I—1 — aDi- )b Site Address:.Address: 3 Cnnr,Aaft w e Q-1 rh fit r y One �},'iJ'1. } , City/State/Zip: C5,)-1 G 7 .ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a da a ainst the violator. Be advised t at a copy of this statement may be forwarded to the Office of • tvestigations the DIA for insura,.e ,overage veri a on. i do hereby certify un e e ains an penalties o pe jury that the information provided above is true and correct. ignatu : _ �`�r.ti Date: (o°t_) 3 I ) a.O 1 i^ hone#: •SlY• i 1`]- 7 7 7 D' 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#: