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HomeMy WebLinkAboutBLDP&G-18 (no number) w/ 67 73 3 �. 000 y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' :47 J 'I Yj 4 /r- ' _ ma CITYi MA DATE PERMIT# JOBSITE ADDRESS / 2/40Gk;rAJariL*'` '6 OWNER'S NAME/ r ? ) it OWNER ADDRESS�,�/IJUY& 41 laeldiJ lV TEL 7i2I O3 r/AX TYPE OR OCCUPANCY TYPE COMMERCIAL Elg1G�uu i_24 `rv °3 'C't RESIDENTIAtd PRINT CLEARLY NEW:D RENOVATION:D REPLACEMENT,';• PLANS SUBMITTED: YES[ NOD FIXTURES 1 FLOOR-4 BSM •1 2 3 4 5 6 ,7 8 9 10 11 12 13 14 BATHTUB I it % -,1-----r. 1[ [ ___ I. r[ ,77_,, -1___ .L^-. CROSS CONNECTION DEVICE I r (�J C... .f .. ,1 ,Jl-,_..: DEDICATED SPECIAL WASTE SYSTEM [ti„It.-IL_. .:r�V[x 771_... ;I-. I4� :I;_._ . 1.,_._.�:�_'[.: `L=.-3 DEDICATED GAS/OIL/SAND SYSTEM C ?_ ,[��;r- I jI +�J 11 [ L_._ - �rL.._ DEDICATED GREASE SYSTEM r.T:l_~�L I -L ;1 :_. I__.:ih u_P�`_ t1,-_ ._LI___ . ETC: DEDICATED'GRAY WATER SYSTEM _'[ ^: -r_ .r-�!I DEDICATED WATER RECYCLE SYSTEM �-, ._ -. _, . I ._, [.— DISHWASHER r- _r7:3E-_7:it- ETD:. �. a.J �:.�. .. . I � DRINKING FOUNTAIN I--.[-'h• (�_�_L__z.; FOOD DISPOSER L _ FIT :�I r- [r�~ _ .-`I[.i ((J ,rI_-_Tr-V FLOOR/AREADRAIN r , - � _ _ ! "� INTERCEPTOR(INTERIOR) [ 1r-TT =1:711- I _:!r.. :.:r, _: KITCHEN SINK (.__ I il� r^'.r-�I. �� r� I � 1-� ;1 1 I. _ I LAVATORY L_' 1_ _1—. . . . ROOFDAIN L 1I r it - -SHOWER STALL - .11_, SERVICE I MOP SINK l- � � 1(-_1 - TOILET '17 1. air-.�_II t1--.,1..:_. .(__. :' _ : _:.., . .[ URINAL 1 _1C ;� �it 1 ,if ;r—T IL7 L WASHING MACHINE CONNECTION WATER HEATERALLTYPES il. I :- L :[_ .177 .... lr ,., ii _ _- -,tr ,(-7:1 WATER PIPING r 1r- 17-1- :Jr [z__, _,1 .. _ 1 OTHER -�- �1P.: I� '.I _ L--(.-I-_i , 'I- C^. (_ -(. ,17_ . .:ice 'L I r- .-5 t INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D+ NO F. IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY D BOND D 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 D 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 tru 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 ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7, l e z. Cite.jam. PLUMBER'S NAME I STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MPD JPD CORPORATIOND+ # 3281C_ PARTNERSHIPL #T LLCLJ# -_I COMPANY NAME ILEZNSLOWErUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I1STATE= ZIP 02664 TEL 508-394-7778 FAX 508-39�4-88256 I CELL N/A _1 EMAIL Laccountspayable@efwinslow.com W u _. Department of-IndustrialAccaaenes rl t Office of Investigations Ir. -�•� 600 Washington Street �',��i' a Boston,MA 02111 • �'� iivWW.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,` �-, Please Print Legibly Name(Business/Organization/Individual): E.,c.W,A n �V��Sl ow `�(k) v, 2- �1.eL` • c' -, )'nC' Address: ' E`?o c) C:irac?— , City/State/Zip: Soo tr't orti-4 s.. MP Phone#: 50S- 3c14- `i?S1 • Are you an employer?Check the appropriate box: Type of project(required): KI 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 Remodeling !.❑ I am a sole proprietor or partner- listed on the attached sheet.# ❑ g ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance, 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 1.❑ 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' 13.0 Other comp.insurance required.] 1ny 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. im an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. /� (� tsurance Company Name: t�lY 1(O•• rt`i1��' ix ce, ovvi olicy#or Self-ins.Lic.#: ‘$ a 1 A. Expiration Date: C,- 1 - apt-) )b Site Address: 3 GriAllAcill 'Q h A i C Q 14 OA City/State/Zip: O,,4 67 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$250.00 a da against the violator. Be advised t at a copy of this statement may be forwarded to the Office of tvestigations the DIA for insurarpet overage veri ca ion. i do hereby certify un e epains ant penalties oft jury that the information provided above is true and correct. (( .e mot^.- 7 ,ram_ �` Date: (`ot 1 2 t1 ©[`��'r ignatei hone#: .5-I)41•.111/4i- 7�7g Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other . Contact Person: Phone#: w10 qty-5- C-33 y�- oo• • I MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK �'�=a- CITY __ ev _ �'�i� MA DATE o • 'PERMIT#m-p -/r` JOBSITE ADDRESS / i 1CIL J &I OWNER'S NAME • - , GOWNER ADDRESS • 12 TEI Yb$_39/. d )91FAXL _ `J TYPE OR icl OCCUPANCY TYPE COMMERCIAL LA ? EDU AL‘41�' RESIDENTIA PRINT CLEARLY NEW:0 RENOVATION:i REPLACEMENT:e- PLANS SUBMITTED: YESD N0 APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1_ I.-.... _..:..,. I — '-_....._.. _ I ,I '- r. Ii_ ;i _ ii . . II__. .._,I 'i._._ ._II _ i....-- `- - ---1 BOOSTER --1- - I_�I_ _.. II.. _ I.. _..II I _____.__-11. ....iI --.. ��-F1, I .L__ -'I i I, CONVERSION BURNER [ . il._ _ .1 _ Jr-. _II ;I, i . I.. _._ II - I ...tI_ sl___ II . ._II----=.ii" COOK STOVE I,_ i i. :I-__' 1 - i 1. .'i . ._. s l - . ._ I 11- 1 f- 1- I ..,I .11 . .,- 11- DIRECT VENT HEATER 1 ----'I - --II_�._if'_--_Yi^- _.,'1- ..'1- l -, .,I-.. - I_. --- . .. -,j- -ll- w-iL-__--_ L..__11 DRYER I 1 ._C_ 'I <L (I_---.il I _( .,..I-_.._ ! .I I _€r. II---_-i FIREPLACE L._. ';L. ___il.. _... ._ I ) _ .._.I.. _i1 i_ 1 1 FRYOLATOR I_ II- 17_. 'f f L ;I-. :I _._ 1,. I . . I !I. . I,_ , I L.. -.Jr-it FURNACE I. I1_v. ..!I. . .. `1 ..II _91 _. _.s--- 1_ . -yi- _;I. . -II-- 11_. - Ii .Er GENERATOR • I_._-. 1_.._....1__. .. f_. I °t... ..I..._ . :1 ... _. !. ' _....! _.i l. .__. ! . .I 1_-__.: _ _._ GRILLE 1- I. I I_ -`1-. ' I 11 I INFRARED HEATER I_... L . (— - i _ I. I.. .., l.. . .LABORATORY COCKS 171-,1— 1--,r- 1-.----i--- FT--k i--- +1 -- �_ �— _ MAKEUP AIR UNIT 1__ILA-_ I.__ I . --,II 'I .I1 i •v�._'i-. 1._.. I . I ,__il^ �_11,_-. • OVEN LT-rI I_ I I_.. r l �_-i l 11 _.I'._- ;L~_ `I_.._. I, _1.1 1.I' .I I. .. .l,_ l i_ POOL HEATER 1- . 1. `I . 1 I_.. 1I- ' �11i -11��`I i1_. I,. )I, . _II _11. —1 ROOM/SPACE HEATER (_il .. -_( _ _.._ i___ .kl,.. •.-.I_ ;I I_.. .1,�....,1 41� :I ,,-_ 'I `n __. ROOF TOP UNIT f_t-11_ .1H_ .�tl. ,3j-- ',I_ 11..77=1. . __1L. 1I %I I:_... ',1_ , II-- 11 TEST H,,- I. _'I 'I_ -'I I _11... . i1. - -;I_ I I ;1..._ L.. In,II ,-..} UNIT HEATER 1--- I • __,I—.._._�.I ,i _.I _ I_. :I 11 __ I, `1 17 I `,I UNVENTED ROOM HEATER f--:3 I 1I. ':IV'- I C ;L III `l_._ (. . .'I _ _ .iL.- rI: . �1 .._�.1I.. ._. I_-_. WATER HEATER — `I . . II .- it '1 f I 1- '; .-.,I_. ..'.1 1.- _ 1. 1.�-i OTHER - - --i 1- 1 l.... 11_ _ f;�.._.`--i "I. L -21 ._ I -1.1 '1.1 --t l`_ `1-.7- ,---�I,.., i II . . `I.. I._ ..i I.. ... _ I -7' .d— - _,i`____-- i ,.I`—,I�.,.�_'I 11 _ I . _ _ 1 I iV _z t�-i-.�_ T IA-sCa'�sGRS++c1l..o..h rw._..-._..-++_._y am �_ ._.. _ - _.... - INSURANCE COVERAGE I have a current liability insurance policy•or its substantial equivalent which meets the requirements of MGL.Ch.142 YES F1 NO F 1 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY El BOND D 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 L 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 d 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 compli ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ „ /1�`/ PLUMBER-GASFITTER NAME I STEPHEN A,WINSLOW ___--1 LICENSE# 12298 SIGNATURE MP El MGF E,:i JP El JGF I LPGI 0 CORPORATION 2#Imc.........11 PARTNERSHIP El#E I LLC LJ#r- 1I . COMPANY NAME: EF WINSLOW PLUMBING&HEATING 7ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH -- STATE r MA ;ZIP 02664 ITEL 508-394-7778 —7 __.• FAX[508-394-8256__ 'I CELL NIA �IEMAIL accountspa able@efwinslow,com . t /.f t 1 •P De•artment of industrial Accaaenrs lfM, Office of Investigations k.two" 600 Washington Street Boston,M4 02111 • o zy wtww.ntass.gov/dice • Workers' Compensation Insurance Affidavit: BuiIders/Contractorrs/Electricians/Phi r bers Applicant Information ii Please Print Legibly Name(Business/Organization/Individual): 'C•�r ,�S i e j �(V� t�i�cl IL t a_\--;:rutQt., hric 0 6 , Address: Q c dcsc C EratZ City/State/Zip: Soo c--,r-KJ-1n ( P Phone#: 50S- V-i-7'77 • Are you an employer?Check the appropriate box: Type of project(required): 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.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. [ Building addition [No workers'comp.insurance 5. C. We are a corporation and its required.] officers have exercised their 10.[Electrical repairs or additions 1.❑ 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.[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. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site tformation. tsurance Company Name: AY" •..•.% (`\i rU aA • olicy#or Self-ins.Lic.#: I B j Expiration Date: (—t - C.)1.1 )b Site Address:::. CC;rwykcyr1 vi-e I-ley, ASS-°, CVAW.sk ' Hi City/State/Zip: C .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure 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 against the violator. Be advised tjiat a copy of this statement may be forwarded to the Office of tvestigations he DIA for insuranee9overage verift ayion. do hereby certify unre 4t ee,ains ant penalties of(p jury that the information provided above is true and correct. i atures " ^ ,ram Date: (`01q # PAW". hone#: .ci'jg 3IW- 77%X 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#: