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Home My WebLink AboutBLDP&G-20-004141 �.--_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t _fir. —' �a. PERMIT#/ �/1/ =.��;� CITY LW/WWII-4 (NC)e% I MA DATE WfflgrAM JOBSITE ADDRESS LOdo D s .CC. f2 2 _' OWNER'S NAME 'J(..)/f [%//4!(_--_ P OWNER ADDRESS D efi N , :h ii-/ i i _ TEL2U3.,;Z g(p 4FAX _ U4,75-7 TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL 0 PRINT PLANS SUBMITTED: YES® N0� CLEARLY NEW:Li RENOVATION:Li REPLACEMENT:�' FIXTURES 7 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 I CROSS CONNECTION DEVICE L 1 '' DEDICATED SPECILDEDICATED GAS//OIL/SANDT - Williall1111111111-0 ,_ NM SYSTEM E M r � _ DEDICATED GREASE SYSTEM I Ipi!min ,--, _ DEDICATED GRAY WATER SYSTEM .Ell MI DEDICATED WATER RECYCLE SYSTEM MIni,E MUM DISHWASHER ISM spromizmumpignon SEImo DRINKING FOUNTAIN FOOD DISPOSER ' FLOOR/AREA DRAIN � , '� �;� �� INTERCEPTOR(INTERIOR) ila I (_ . KITCHEN SINall �' illi LAVATORY ;� _ !!.�!®1.1. 1 ROOF DRAIN fnI�_ �I�W_iMumIMMINIENE SHOWER STALL MINIM rr,IMMII!IMINIEWIPIRWIN SERVICE/MOP SINK = 1 TOILE WASHING MACHINE CONNECTION Imo'URINAL MF111111 raira.....pi 1111111111111111111111111101 WATER HEATER ALL TYPESMR WATER PIPING IA�lll�l�11' 11 OTHER il i I 4 r...r. rEll rIIIIN I F 1 �� INSURANCE ERAGE: \ I have current liability insurance policy Ior its substantial equivalent whichhv meets the requirements I a p y of MGL Ch.142. YES LE NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY Li BOND LI 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 [11 AGENT fl 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 it a to the b t of my knowledge vand that all plumbing work and installations performed under the permit issued for this application will be in co Ii wit yertine proyisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � l/�-,, PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MPLI JP ID CORPORATION O#I3281C 1PARTNERSHIPL# ILLCL1# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY I SOUTH YARMOUTH I STATE MA ZIP 02664 TEL 508-394-7778 FAX 1508-394-8256 I CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts • a_ Department of Industrial Accidents �i:remoo: = Office of Investigations _��1�a Lafayette City Center J 2Avenue de Lafayette, Boston,MA 02111-1750 ".,"/ www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E.F. WINSLOW PLUMBING & HEATING CO, INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Business Type(required): 1.❑■ I am a employer with 90 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. El Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.#1909A Expiration Date:01/01/2021 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§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 the DIA for insurance coverage verification. I do hereby cer ' e the and penalties of perjury that the information provided above is true and correct. Signature: /Y . -A - 01/02/2020 Date: Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 FA - 'H i CITY I/fhM1�� „�ld.�0 MA DATE'//2/ '.J PERMIT#R� O-CV e/N/ L ,%� S /-f7/_i �/� OWNER'S NAME I'T(>/1/ 4 fiv _/z- JOBSITEADDRESS (t%� �' '� G �0 A�SvN - b ill Litf£�+ l'l �TE ,2t)3 62 /FAX 1 OWNER ADDRESS i�' TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL® RESIDENTIALD PRINT PLANS SUBMITTED: YES® N00 CLEARLY NEW:® RENOVATION:Li REPLACEMENT: APPLIANCES 7 FLOORS BSM 1 2 3 4 - 5 6 7 8 9 10 11 12 13 14 BOILER O-� —1 BOOSTER N—��- �® CONVERSION BURNER MI - ' ® COOK STOVE 11 , ' LI 1111 DIRECT VENT HEATERMI iL DRYER -MN. f FIREPLACE �' —1 F OR FUURNACRNAC E GENERATOR 11111111111 1 . 1111111M, GRILLE IIIIISIMI '®_ NI1111111111==MI � { —� INFRARED HEATER I__ �� sr LABORATORY COCKSMMIIIII ' �� rni- MAKEUP AIR UNIT ME1- �� j - PimillEM OOEN � I �. POOL HEATER ��,, IIIIII ROOM I SPACE HEATERMillaMillill ROOF TOP UNIT I -- Maranan �MI�_ TEST .M{ _M� UNIT HEATER - I milli UNVENTED ROOM HEATERMINNIKEMNIIIIIIIIIIIM I WATER HEATER �- 1.— a- - OTHER I — -- � (` . mirnall 11111.11111111111111111 WINOINIIIIIIII INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L NO [_ 1 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW un \-,, LIABILITY INSURANCE POLICY ji OTHER TYPE INDEMNITY BOND Ni) 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 I. SIGNATURE OF OWNER OR AGENT to the I hereby certify all plumbing all of the details and information I have work and installations performed under he'tted or permit issueddfor this application application wi l ben e true and accua F)ertine b provission of the knowledge and that p 9142 of the General Laws. R-- ,....A.-�- ,.` Massachusetts State Plumbing Code and Chapter compliancr lV PLUMBER-GASFITTER NAME I STEPHEN WINSLOW I LICENSE#I 12298 j SIGNATURE ®# I MP LJ MGF Q JP I JGF❑ LPG' CORPORATION Q#13281C I PARTNERSHIP 0#I COMPANY NAME:)E.F.WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE I I -- CITY I SOUTH YARMOUTH I STATE I MA (ZIP 02664 1TEL 1508-398-7778 FAXI 508-394-8256 I CELLI NIA IEMAILI INSPECTIONS@EFWINSLOW.COM I - • The Commonwealth of Massachusetts Department of Industrial Accidents 9,'I -,' Office of Investigations g°ilk `,l Lafayette City Center a,�� 2 Avenue de Lafayette, Boston,MA 02111-1750 °�� ;� www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E.F. WINSLOW PLUMBING & HEATING CO, INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Business Type(required): 1.❑■ I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1 I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.#1909A Expiration Date:01/01/2021 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§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 the DIA for insurance coverage verification. I do hereby cer ' R the glzzins�penalties of perjury that the information provided above is true and correct. (�/ 01/02/2020 Signature: Y Date: Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 1❑Board of Health 2.0 Building Department 3.1=1 City/Town Clerk 4.0Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: