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Home My WebLink AboutBLDP&G-16-004066 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK, 11 • _tfailffe ,��. = CITY MA DATE h .µ,. l,C PERMIT#1 �'�'�'Sid �`� JOBSITE ADDRESS t-,— CiMtC1 `� , i OWNER'S NAME ��' ,,; ' P OWNER ADDRESS a)k`C),.;YMhV\n \.i...... : --- TEL FAX ...,. TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL Li RESIDENTIAL; -"- PRINT PLANS SUBMITTED: YES El NO CLEARLY NEW:11RENOVATION:I . ONREPLACEMENT:� FIXTURES 1 FLOOR-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB — — um CROSS CONNECTION DEVICE INN iiiiiiii.1111111110111111115 N Nig' am emir No mum no N DEDICATED SPECIAL WASTE SYSTEM amtang eicempaptigg umNM no amMIN NU Mill au ma DEDICATED GAS/OIL/SAND SYSTEM am MIN SIM MN MR DEDICATED GREASE SYSTEM amisisamtiatimomeni ow ma inni_iiiii.NM NMMI iiii DEDICATED GRAY WATER SYSTEM � „ � f.. DEDICATED WATER RECYCLE SYSTEM Ii'� i -- DISHWASHER W _ r i . _ DRINKING FOUNTAIN NW - latims FOOD DISPOSER amiumiimintiarammasuilami am , FLOOR;AREA DRAIN NIWIOIIIII INTERCEPTOR(INTERIOR 11111111111111111111.11a i. KITCHEN SINK iNininiiiiiiiiiir . IMIIIIIM ROOF DRAIN ilitilnitilii aim am 1011011111111111111.4•1111111111.111111111111011111.11 SHOWER STALL_ no MINIIIIIIIIIIIIIMINIIIMMONIIIII SERVICE/MOP SINK 1111111111111111MM all MIIIIIIIMIMIRMINIIIIIIIIIIIIMIM TOILET • URINAL 10111I — WASHING MACHINE CONNECTION __ a _,WATER HEATER ALL TYPES _..:- _ . 1101011110.111111111111111111111 WATER PIPING OM allismi;i .._. :. INIIINNIIIIIIMNMNIIIIMINIIBIIIIIIIIINIIIIMSIIIIIF OM IMP ._ OTHER MO—an imapialiamtant INSURANCE COVERAGE: t I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO Li IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY t"( OTHER TYPE OF INDEMNITY [ BOND ;_ OWNER'S INSURANCE WAIVER:I am ailvare 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 Li AGENT L,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 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 compt ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ f r2 / PLUMBER'S NAME I STEPHEN A WINSLOW LICENSE#,12298___,1 SIGNATURE MP JP[J CORPORATION' #I3281C _ ,(PARTNERSHIP®#I, ,. . JLLC}LJ#L COMPAN Y NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS f 8 REARDON CIRCLE CITY SOUTH YARMOUTH J STATE'MA j ZIP [02664 TEL 508-394-7778 FAX 1508-394 8256 CELL EMAIL 1 ACCOUNTSPAYABLE@EFWINSLOW COM The Commonwealth of Massachusetts —,—= Department ofIttuastKalAccidents -=Ai=- 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(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: Type of project(required): I.ID 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.❑ 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 workingfor me in anycapacity. employees and have workers' p n 9. ❑Building addition [No workers'comp.insurance comp.insurance.t required.] 5. ❑ We area corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c.152,§1(4),and we have no 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. :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 eery 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 oft IA or insurance'co erage yeti cation. I do hereby certify un e. •ns and enalties ,perjury that the information provided above is true and correct. Signature: A �� 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: hone#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK &lam. Q. CITY I. MA DATE \ t(49 PERMIT # /*---0/9-/b --0014/6 k,r) • JOBSITE ADDRESS ; OWNER'S NAME Ai, alk dna& 111111 e VVI OWNER ADDRESS FAX • TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL .J EDUCATIONAL RESIDENTIAL CLEARLY NEW: . RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES I N9K, APPLIANCES -1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER J _1 CONVERSION BURNER COOK STOVE _ .J, .11,__I . I . 1; 1 DIRECT VENT HEATER _ ...I _ I .„,„, I __I DRYER 1 _ 1 ___I i j FIREPLACE I I _ FRYOLATOR J 1 FURNACE [ _„„ I I I ___ri I GENERATOR I . _ . 1 I I 1 I GRILLE _ I I t I _ I 1 _ I: 1 _ 1 , , . INFRARED HEATER .1-; J 1 I • 1 I I; . I LABORATORY COCKS _I, I _1 MAKEUP AIR UNIT .... I I J OVEN I i , „ J „___,1 POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER 0*. . . . UNVENTED ROOM HEATER WATERHEATER L OTHER ° - _ INSURANCE COVERAGE I have a current [ability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ; NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY x", OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: ! am aware that the !icensee 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 compli nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. biz-6/ PLUMBER-GASFITTER NAME STEPHEN A WINSLOW LICENSE # .A.2298 SIGNATURE MP V.XMGF JP JGF I LPGI j CORPORATION # 3281C ; PARTNERSHIP # _I LLC .. . COMPANY NAME: E.F.WINSLOW PLUMBING & HEATING I ADDRESS 8 REARDON,CIRCLE m CITY SOUTH YARMOUTH STATE MA ;I ZIP 02664 TEL 508-394-7778 0000.0., • .04•M 00 ,W.N. •v eArer FAX 508-394-8256 CELL i EMAIL ACCOUNTSPAYABLMEFWINSLOWCOM 00 : - .4-iicc? ' Lin q- -4)0 ter LR The Commonwealth of Massachusetts Department of h niustKal Accidents = i_ t 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 E. F.WINSLOW PLUMBING&HEATING CO.,INC. Name(easiness organization/mdividuaq: 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): 1.111 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.El I am a sole proprietor or partner- listed on the attached sheet. ;. ❑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 are a corporation and its 10.❑Electrical repairs or additions 3.❑I am a homeowner doing all work officers have exercised their 11.❑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 employees.[No workers' 13.0 Other 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.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 oft IAor insurance co erage vert c�tion. I do hereby certify un e. ins and enaltiesrjury that the information provided above is true and correct Signature: A / U �/� 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#: