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Home My WebLink AboutBLDP&G-16-005189 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,; _c� _ a — l=t': CITY jtl �(` ...1I C , �_ MA DATE 1 1 1 j PERMIT# OP-lb—CV 97 .:�, JOBSITE ADDRESS OWNER'S NAME • 3 POWNER ADDRESS T ''jc_ { IFAX ' CZ-71CCr� Cj e^ c TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL � ` PRINT CLEARLY NEW:Li RENOVATION:-,,,, REPLACEMENT:* PLANS SUBMITTED: YES_I N00, FIXTURES Z FLOORBSM 1 el f ' i,11- mi M1 BATHTUB CROSS CONNECTION DEVICE ,R DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ` DEDICATED GREASE SYSTEM �=imilliii= ==iminum:iiiii_ DEDICATED GRAY WATER SYSTEM 101111.111Willi alitillW11011 INIff MINN DEDICATED WATER RECYCLE SYSTEM laraintimi mg getimigun am allIWITM10111.1WM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR is ' KITCHEN SINK CONNECTIONLAVATORY INIT01111111111111111111111111110111111•111111fillO11100111111111111101111110111111 SHOWER STALL MIIIIIIIIIIIIIMMANIIIIIIIIMM11.11•11,11•1111111,11.1 SERVICE/MOP SINK IIIIIMIIIIMWIIIIIIMIIIMIIIIMIIITMIMISIIIIIIIIIMIIIII OW MINN WASHING MACHINE OTHERWATER HEATER ALL TYPES I IIIIIIIIIIIIIIIMIIINIIIIMIIIIINWIIIMIEIMIIIIIIIIIIIIIIIII am iiiimmo.gni ow WATER PIPING IIIIIHIIIIIIIIIIMIIIIPIIIIIIIIIIIIIIIIIIIIIIIIIItillit NM IIIIIIIIIIIIIII MN 1.1110111 11•1i.. lommumumannummomiimillitiTISMEISIMIIIIIIIIIMMINIMINIIIIIIIi MINXIIIIIII INSURANCE COVERAGE: I have a current liability_insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ..4OTHER TYPE OF NDEMNITY !_, 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 L- AGENT 12 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 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 I LICENSE# `12298 jj N_ SIGNATURE MPY\1 JPI CORPORATION' #j3281C -IPARTNERSHIP # LLC0# COMPANY NAME I E.F.WINSLOW PLUMBING&HEATING 3 AD RESS 18 REARDON CIRCLE CITY SOUTH YARMOUTH ..__1 STATE f MA t ZIP €02664µ TEL TEL 508 3947778 — FAX 508-394-8256 CELL I EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM _______, w. 6,K Ett,. ; z.„/:\c il-- L9,.._.. 't.d_tice,2,,u, The Commonwealth of Massachusetts Department of It a'Zr sfFtsl Accidents _:::lilt=Ct Office of Investigations _ '_�� 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(easiness/organizatiot✓lndividual): E. F.WINSLOW PLUMBING&HEATING CO.,INC. Address:8 REARDON CRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): I.❑■ I am a employer with 70 4. ❑I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.Q I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.t 9. ❑Building addition required.] 5.❑ We area corporation and its 10.0 Electrical repairs or additions 3.Q I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c.152,§1(4),and we have no 13.Q Other 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. :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.#:1794 A Expiration Date:01/01/2016 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 Section 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 imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of IA ffirinsurance/co erage veri cition. I do hereby certify un a ins and enalties eerjury that the information provided above is true and correct. •Signature: �� CA- Date: 2016 Phone#: 508-394-777 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: '—Phone#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ,A► i i. i�r., ;.. .... ,� ,.. �.r, MA DATES 1C PERMIT # hz4P--M - S 8 JOBSITE ADDRESS !OWNER'S NAME OWNER ADDRESS FAX TYPE 4R OCCUPANCY TYPE COMMERCIAL EDUCATIONAL w w .) C • 3j3il E ID TI � PRINT CLEARLY ' NEW. TT: RENOVATION: REPLACEMENT PLANS SUBMITTED: YES :-.:,.. N0 APPLIANCES 1 FLOORS—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ran ,. .r.,. w . BOOSTER ' wehrry-w bYNmgpgsax.e. �..-a.maymggxyER .9195 '�aCm'+•M ,$ ....•nwi-^ ..MR.eYw^l+".'.•� • +4+Kt&4.e +^M'«'.f CONVERSION BURNER COOK STOVE I I , I ._.,-_., _.,.�. DIRECT VENT HEATER DRYER FIREPLACE .._...._.. .�....._....�. . . ; ^W�._... .... _ � 1 FRYOLATOP, .......,„ 1 - , .- ... , FURNACE 1 ' GENERATOR GRILLE , •_ I .. .: l I 1, i 1 .. INFRARED HEATER LABORATORY COCKS _ . ... ... — . ..� ....w�._ _ . .� i . .. .. �,._.� MAKEUP AIR UNIT �.� OVEN ._.—_. .-. POOL HEATER - .. .". ROOM / SPACE HEATER ROOF TOP UNIT ww t' .w-. .. w . ': .w.. , ._.4�. �.� . k .1 .TEST E£ k. E remv� f UNIT HEATER ' UNVENTED ROOM HEATER ; WATER HEATER �_._..� ww.......�.,.� _.. . OTHER i • _. - ' ......: ..y.... � ............ . ..... .. .... ..�w�....7tit� .........—...... ....r............ m.. 9 1 a.a..q..w......, we.wlF+f mr. .^•"K M^ .. _ _ ~" ....M INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO , a: I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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 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 e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , • i PLUMBER-GASFITTER NAME STEPHEN A WINSLOW LICENSE # .1.2298._...r_ SIGNATURE MP XMGF JP JGF LPGI CORPORATION >ilc# 3281C PARTNERSHIP # LLC �,.# COMPANY NAME: E.F.WINSLOW PLUMBING & HEATING ADDRESS . 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA '.ZIP 02664 j TEL 508-394-7778 , FAX 508-394-8256 x j CELL:— EMAIL ACCOUNTSPAYABLE aEFWINSLOW,COM _ ry^A � ^M^ ....M�. .. w..'. YtT t (er Lapc: (E,c,pj . ..,;1.) cp The Commonwealth of Massachusetts — 1 Department of Ika�i sMal Accidents Office of Investigations _�'=a" 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E. F.WINSLOW PLUMBING&HEATING CO.,INC. Address:8 REARDON CRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: 1.0 I am a employer with 70 4. 0 I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.: 9. ❑Building addition required.] 5.0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their I I.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL insurance required.]t c.152,§1(4),and we have no 12.0 Roof repairs employees.[No workers' 13.0 Other 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 subcontractors 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.#:1794 A 01/01/2016 Expiration Date: 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 Section 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 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 t IA or insurance oo erage veri cAon. I do hereby certify un a ns and enalties erjury that the information provided above is true and correct Si ature: CA- 2016 Date: Phone#: 508-394-777 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#: