Loading...
HomeMy WebLinkAboutBLDP&G-18-005015 ` WORK MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING ,t=�a i MA DATE ki5 ( ! 1- PERMIT#. __!. /. �ID E CITY : > —cs- �T JOBSITE ADDRESS Leif % OWNER'S NAME? } r ► r '�� S ID OWNER ADDRESS 1 /C1 • r 7 TELX- 1,�LFAXI TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL [J RESIDENTIAL PRINT PLANS SUBMITTED: YES[ NO[ CLEARLY NEW:® RENOVATION:0 REPLACEMENT: FIXTURES FLOOR-4 ciao 2`^3 4 5 6 7 0 9 10 11 ®®� BATHTUBMINIL IrT— ' CROSS CONNECTION DEVICE �I-_-.�'I--==-.. •- --,--;1=�-..: �_.:__!L:.-_ I,_.._...t® ; :-.- :n KIMMN 7 -- DEDICATED SPECIAL WASTE SYSTEM �__ in _1= mm��� DEDICATED GASIOIUSAND SYSTEM I , +T. I -1 ==}I ;�® ®®® DEDICATED GREASE SYSTEM ®I I. .. ,_:I_ I-.-:-.__ _ _-:. -_.__._- F ®�® DEDICATED GRAY WATER SYSTEM :I-- .-Ir^ ,--. -:1L. ..J -M='1- :'®®�®®®® DEDICATED WATER RECYCLE SYSTEM I i r r I 7:11 .- `[.'-' ''11:®® ® M DISHWASHER -.7 =--^.,______ ____..-- _- -i_._...._ DRINKING FOUNTAIN ®I�:�-4^I..._.:: +:I ,..-ri _. I_7.. _:_1I__= 1.._._.!®®® MMIlltionlin istr FOODLRISPOSERAREAD _ . .L_ I• _II ---_1L_ _.::II_::..-:'®�®®®® NNI INTERCEPTORO (INTERIOR WIN A- I' ®®®®®®als LAVATORY ®® .:_E-_._'I ..`11,.__IL�_ '�®® WIWM� ROOF DRAIN ®®I. : '1--.E.. ..[...,�_:_,I_:_ I,.. ..,.__�®®®®®� SHOWER STALL ®® -°E71 :11- ,L, _ _-,®�®®® SERVICE/MOP SINK �� I. '"_ ®®®®® TOILET URINALIMF = WASHING MACHINE CONNECTION I____:.1 i-:.-.'y'° [` ` ����®®[� monsit WATER HEATER ALL TYPES *-:.- I I _ I� ;.__iL WATER PIPING _L -II- I- 'I . . II. ... _ L i 'I . ..1 OTHER _,:._:._L _ - _ --- - - - i I _I. L- _- -- - n -!I�._-.LEI:, ..-®um® -- ----- 1. --�.� _— =RT_"_`." —",.. —._T INSURANCE COVERAGE: I have a current Iiabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[,3+ NO i IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW l_w LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY BOND DI n 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 SIGNATURE OF OWNER OR AGENT I hereby allplumbing certify that all of the bing work and installas tinformation I ons performedhave submitted or under the permit issued for hisding applications plication are true accurate to the best of my willl be In comp) a with all Pertinent prov s on of th edge and that�II'I � Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A•WINSLOW - .LICENSE# 1 E SIGNAT RE 2298 MP El JP 0 CORPORATION lj# 3281C PARTNERSHIP[# 9;;LLC0'# _,__ COMPANY NAME EF WINSLOW PLUMBING&HEATING ri ADDRESS 8 REARDON CIRCLE .__ � — r — CITY SOUTH YARMOUTH STATE MA ZIP 02664, ,..___..__ I TEL 508 394 7778 _ _ EMAIL (accounts a able efwinslow,com - ---1 Z/ FAX 508-394-8256 �CELL NIA �r.._....._.� �•p-�` .°� ----�----•---•------�-�-W _ ""." - �� .�.� 1 The Commonwealth of Massachusetts vet Department ofIndustrialAccidents =;;life „ 1 Congress Street,Suite 100 Boston,MA 02114-2017 "I www.massgov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. .A 'leant Information • Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC please Printedb'v Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664. Phone#:508-394-7778 Are you an employer?Check the appropriate box: 1.�✓ I am a employer with Business Type(required): employees(full and/ 5• 0 Retail or part-time).* 6. ❑Restaurant/BarBating Establishment • 2,El I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 3.0 [No workers'comp.insurance required] 8. 0 Non-profit We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c.152,§1(4),and we have 4.❑ no employees.[No workers'comp.insurance required]* 10.❑Manufacturing We are anon-profit organization,staffed by volunteers, with no employees.[No workers'comp.' 11.®Health Care : p insurance req.] 12.0 Other �y applicant that checks box#I must also fill out the section below showing their workers'compensation policy infonnation. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is r organization should check box#I. equired and such an tam an employer that is providing workers'compensation insurance for my Insurance Company Name:ARROW MUTUAL INSURANCE COM ANemployees. Below is the policy information. Y Insurer's Address:23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL,MA 02467 Policy#or Self-ins.Lic.#1821A Attach a copy of the workers'compensation policy declaration page(showinEthe ption olicybate:01/01/201 Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of c criminal Iration penaltiesdate number and 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi Ai. the a' s and enalties o perjury that the information provided above is true and correct fit/ Si nature: �,,, ' ' -•.� Date: I. / r hone#:508-394-7778 Official use only. Do not write in this area,to be completed by city or town official • City or Town: Issuing Authority(circle one): Permit/License# - 1.Board of Health 2.Building bepartment 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: 1 wwwanass.gov/dia • • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . VW_ CITY~ r'^ • C •1 MA DATEII „ U 1 PERMIT#� ',/�'/�'-t Or JOBSITEADDRESSI_4OWNER`S NAME.E.- ; C" OWNER ADDRESS I BC\ {{ 11 l� 't►I �S : T EL AX .-.] `� TYRE OR ARESIDENTIAL 0 v � � OCCUPANCY TYPE COMMERCIAL0 EDUCATIONAL[ CLEARLY NEW:O RENOVATION:Ei REPLACEMENT:0 PLANS SUBMITTED: YES° NOO Q APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 . 12 13 Mil BOILER __ ' . .'1 .-. I i I. .I= :-1-.--;1_ .41__-..? � BOOSTER I--1 1- I, i _ _'r-:-wr -7 _-7 : . E ` } N CONVERSION BURNER _ � T �i®l _ I. .. _, :I,- >( T r Cam:. r -' IKOWNIN COOK STOVE I�_ I_ �; ___ _. =:1 'i ` 1111111 11MI® . DIRECT VENT HEATER _r :1:3 '�l f7-,Ir::.._�[ _v:lI___. iIl=,.:.n( . -�II- * ... ,smillillygo[ O DRYER FIREPLACE . L, '�- 1. ` :-.-'I "` ;1- ----1 -i' .__ - +I lirilai rI FRYOLATOR I- •`I r vi I- .._w.'i.. r -r 1__._.�t'u...��I. _`[. .E:. `1� v:L._. FURNACE GENERATOR 1._ i ' -- .---- -- :1_...._,.1..-.- ,r...... fi 11111111111111111 GRILLE _,11. i :I. _. _,I:. µ rK_. _,1 .w_ :;'.. :, �1 . 11111111111 INFRARED HEATER L—,i LV_.___1. ':I . 'I,7I: ;I .-'I,- ._.I..�.....�.1® C_�--'--. � LABORATORY COCKS ®®l. .-.(----1" I.�.. '.r_— r.- 71.— '® � MAKEUPAIRUNIT ®�I�T'I'1.� -!L. :r.� !L_7'L:.. L., _'®L_ :Iv, — ®� OVEN r...�._,I� :r.-- �� ,r.. _if ____.r.---u:I.- ®I..��'I. POOL HEATER C._ i f—1_.-_.-r: ' ----;f -11� • —i;®I_-,.7:I,_ ®�® ROOM I SPACE HEATER ROOF TOPUNLT L-_.._:1- II _.-1117E 'fl i -V,L7MOI.7. - - - =� tots TEST 1 _ _ `1-_-i --,1_.--.1--'-—.r -1 Y'�i,. •I ,��® iime UNIT HEATER 1�_.—,,1- —. :ET- L I•—— r-- -<•1.. I.,.'-_ -1-- iI.. -- C_ ®�� . •UNVENTED ROOM HEATER [ _34L �:..1-_ .E;_ ',I .1 _ i. —1[�_. L__'®��®® WATER HEATER ��. I+__r---I_�.[ -- -- -,l•--1- —'1 ,.-1 !�_ 17,..,.:1:.;_--., OTHER[ � I - 11---- i r__71- "I1..�._:�• .'I• •_.v.,�.__(�--;j,.._.,i.,:- L---�;�', � --- ;(77.11 ij- lI IL,.Azr• I. r 1 L .L.. [:',; ii.,._..-_ �� C F--------— 1 1:-.--).17:IT"'...`r— ii--.---..*----,r --:Ire:- '1:f.-111111.1INIM1111111111101 clY INSURANCE~COVERAGE 9 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch:142 YES [EiNO bo l IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY EI OTHER TYPE INDEMNITY 0 BOND 0 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 0 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 an' = urate to the best of my knowledge and that all plumbing work and installations performed under the permit Issued for this application wit be In compllan'.I'th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4 / - PLUMBERGASFITTER NAME t_STEPHENA.WINSLOVV 1 LICENSE#[12298T, /�SIGNATU• MPI I MGF0 JPO JGF LPGID CORPORATION #r3281C , PARTNERSHIPI_._IIT LLC1#. �_.� COMPANY NAME: EF WINSLOW PLUMBING&HEATING I ADDRESS)8 REARDON CIRCLE ____ __ _.,— .:! CITY ,SOUTH YARMOU T H _ '1 STATE DMA I ZIP 02664 _ITEL 1508-394-7778_,_, _________________, FAX 508-394-B256 1 0E4NIAEMAIL accountspayable@efwinslow.com — ...�--- -- -`l . . le ,,, . . , 1 1- 1 1 1 The Commonwealth of li'assachu,setts SiSe Department of;1�M' ndustrzal accidents 1 A E e. Congress Street,Suite 100 .� .� _Roston,1 q 02114 2017 Y/''av Workers' p www.m4sgoy/dia tom Compensation Insurance Affidavit:General Businesses. • A licaut.information TOBEFI>ED WITEf THEPERMITTING AUTHORITY. Business/Organization Name:E.F. please print Le ibI . WINSLOW PLUMBING&HEATING CO,,INC Address:8 REARDON CIRCLE • City/State/Zip:SOUTH YARMOUTH,MA 02664, • Are you an employer?Check the 'hone#:508-394-7778 appropriate box: 1.ElI am a employer with ( Businfesse(refred). or part-time).* — employees(full and/ 5. 0Retail 2.El I am a sole proprietor or partnership and have no 6. QRestaurantB ar/Bati g Establishment 7• 0 Office and/or Sales incl.real estate,auto,etc.) employees working for me in any capacity. 3•0 [No workers'comp.insurance required] We are a corporation and its officers have exercised 8• Non profit their right of exemption per c.152,§1(4),and 9• 0 Entertainment n eirright ofe we-have - iI`Io workers comp.insurance r Q Manufacturing 4.❑ We are a non-profit organization,staffed b wed] 11.®Health Care with no employees.[No workers'co Y volunteers, comp.insurance 12.0 Other #Airy applicant that checks box#1 must also fill out the section below showing Their workers'compensation policy information. "If the corporate should officers have exempted themselves,but the corporation has other employees,a workers'compensation organization shoulo check box#l, policy is required and such an lam an employer that is providing workers'compensation Insurance Company Name;ARROW MUTUALN uisurancefor my employees. Below is the policy information. INSURANCE COMPANY p y f Illsnrer'sAddress: • 23 COMMONWEALTH AVE City/State/Zip; CHESTNUT HILL,MA 02467 • • Policy#or Self-ins.Lie.#182IA Attach a copy of the workers'compensation policy declaration page(showingxpi policy 1I2 expiration�_ date). Failure to secure coverage as required under Section 25 p Y number and fine securec vera/or one- ear' A ofMOL c. 52o mposifion of criminal penalties of a Y 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 Investigations of the DIA for insurance coverage verification of this statement may be forwarded to the Office of t do hereby cerfi , r they a' I ii nature: Jae amities o peryuD'tltcrt U1e information provided above is true and correct ' 'hone#:508-394 7778 Date: 1 31 /1 • Official use only. Do not write in this area,to be completed by city or town official City or Town: fh Issuing Authority(circle Permit/License# 1,Board of Health 2,BuiIdingbepariinent 3. • b,OtherCity/Town Clerk 4.Licensing Board S.,Selectmen's Office • Contact Person: Phone#: