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Home My WebLink AboutBLDP&G-17-06075 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK a =y CITY4LØtJ7MA DATE //- / RMIT#/�/9-17- 90(YU79 *` JOBSITE ADDRESS - *�/ ,¢j//kji/ `,� ij/ /iOWNER'S NAME? ii1)1 1 1 E OWNER ADDRESS . .r TEL i 6/f'75-4/0,6 ,FAX 1 'a PRINT TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL lEr PRINT CLEARLY NEW:Ei RENOVATION: 2 REPLACEMENT:JD PLANS SUBMITTED: YES[ NOl.- ' FIXTURES 1 FLOOR--I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 'r----, .r_�_r^-C.. ![-_ J� ___r .. , ',_ .. CROSS CONNECTION DEVICE �-I--T I��_�( _ [:"-7�{ I ;(-- .r��r I #f.-_�l—dl l DEDICATED SPECIAL WASTE SYSTEM L T 11i .. . T [— ii -,l F. ,i _IL ;I-_ ,I,_, j(-.'(--i(--1 [7 Ir E. i -7r- r7r l� I , DEDICATED GREASE SYSTEM 1_~�I '1 DEDICATED GAS/OIL/SAND SYSTEM i�T- � . , - i .,.�_Il ;�- j( --{II ^j�_-_ ._li.__�I- r-:�- DEDICATED GRAY WATER SYSTEM i [- ,1 ;i j j ij(�-°(-P-11 .41.- Jr--ili- v DEDICATED WATER RECYCLE SYSTEM E.' E(�-i' 1 r IT1 li ;[ -L - ;I 11� III— 'r-- DISHWASHER 1: �- I. I -. - r-,_c l -{ ._ r. - i 'L iC-I - L_ VDRINKING FOUNTAIN j I .Ii --[ :' n r-r _ t-- I FOOD DISPOSER L..� r r-I_ - ..__ ,r_,- I1-I -. (— _ .: I-1 r._ • FLOOR/AREA DRAIN I____ T_EI. t _:-_-1 . I _ 7d _ . 'C-_ -` --_ r—__-r- -- INTERCEPTOR(INTERIOR) 1[- Iryir— r~,[ ?1 ' Ir ( _7. S-__i_ ![ -r • . ° ' KITCHEN SINK ._- 17-I I^~i!�1--'I- _ _TI r_ i -- `i i LAVATORY _. r-_ : I _ _i_ T I ,.-, r r _ 'I--- 1- . [_---''1 _ -77— ROOF DRAIN _-II -,: .- ;I—I i1 i� .._,ll :7-I'l__ 1 .`i_-f[----[---:fi-..._-.�-[ SHOWER STALL -1T I[. , , !r- �i �<i_ . Jr__ JI , l -;I,__� . )L_r_�-_i�__;I . r.:-. -I SERVICE/MOP SINK I ir-.� _ i [— 'I--2I ir-iFTP 1['______1 l f TOILET 1_1I — I : _1 IT L _ _ ,!�_ 11__IL_ , 'r-' !,�-I 1 1L�_ _. URINAL 1C i...- .IL . to:[- _ ri ,I[ _ I 'r.- ,[T__:,P+l _-- —:.� _ WASHING MACHINE CONNECTION _ ,,,_,91 :r- ir-_; .,e'll_ _. !1 I ' [ (~-( ' _._._, 'I—�[_ J WATER HEATER ALL TYPES L ,. iii 1- L, _.'.1_ - _'r i IF_..,..i _. ..IT L_�_ ^i.._ ..._I. ___ 1= ._-, WATER PIPING IT_ir--;i� 1.7--t[-�;=�V,P-1[� r_ r �i_�[- -. i i OTHER._ ... ..T-T- ir-. P .C_ r I r—.1-i[--i__ . L 6 �I�� .� ,�— i17. l_.__r ;r _Ir il :r--- f ;i_7717—,i--_;i—�;1 _,r- FL INSURANCE COVERA- GE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Li NO ri IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE I3Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY tm. OTHER TYPE OF INDEMNITY J BOND El 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 ID AGENT D 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 com ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 t SIGNATURE MP1 JP El CORPORATION Eli 3281C !PARTNERSHIP#r LLCD# , COMPANY NAME EF WINSLOW PLUMBING&HEATING ; ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE ZIP 02664 T MA TEL 508-394-7778 FAX 508-394-8256 I CELL 1 NIA 1 EMAIL accountspayable@efwinslow.com l nvestigations ington Street MA 02111 • • iss.gov/dia 40 It: 1 uilders/Co>int>ractors/Jlectricians/Plunabers - Please Print Le 'bl v 4c' �i \ Phone#: g- 399-77'n ►r, , eral contractor and I Type of project(required): • at iii.;' the sub-contractors 6 ❑New construction El partne e attached sheet.1 7. ❑Remodeling 1eS contractors have 8. 0 Demolition apacii omp.insurance. 9. 0 Building addition any' orporation and its .i. ✓e exercised their 10.0 Electrical repairs or additions C omption per MGL 11.❑Plumbing repairs or additions 0,and we have no 12.[]Roof repairs [No workers' -ance required.] 13 ❑ Other ny a; tome heir workers'compensation policy information, nitre ;hen hire outside contractors must submit a new affidavit indicating such. ame of the sub-contractors and their workers'comp.policy information. tm i urance for my employees. Below is the policy and job site for; sura )lie} Expiration Date: (—i — ,X)1—) b Si Y '�" l U City/State/Zip: 0,)1-4 6? ttac' in page(showing the policy number and expiration date). iilur 'L c. 152 can lead to the imposition of criminal penalties of a ie u' ;ail penalties in the form of a STOP WORK ORDER and a fine up t )y of this statement may be forwarded to the Office of vest. /..-__-- toh the information provided above is true and correct. tea. Date: d Z) 3 i ) aa01( lone Oft y city or town official. • Ci t rmit/License# Issi 1.1 6 it2lerk 4.Electrical Inspector 5.Plumbing Inspector Co; Phone#: • —_ � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • ra Ir_c c CITY Ik✓.- '.' -_ ` _ . .._ MA ATEL C' - +I P RMIT#X0,-/7 d0 7, JOBSITE ADDRESS i i / 1 C79r1` /II2L OWNER'S NAME mj l) J YOWNER ADDRESSI TEII -/ / FAX TYPE PRINOT OCCUPANCY TYPE COMMERCIAL[j EDUCATIONAL D RESIDENTIAL } CLEARLY NEW:DI RENOVATION:D REPLACEMENT:Ef-". PLANS SUBMITTED: YES} NOL APPLIANCES-1 FLOORS-+ BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER r-�-1. _'1 71 - 'I } I.. ^i ;i f' __I BOOSTER E. :1 I I_ .1-1- _ 'I �: .,I I II I „� CONVERSION BURNER ( TI I- _ I I tI-. . tl 'I� II —!I�"11 1LWy COOK STOVE I I I i il 11 , —;I ---Li- I N. DIRECT VENT HEATER I -I I______.'I- T1 I ? l - - I z_I I �!! ' -l l DRYER I i -1[ -;1. r.. I t " 1 I i i 11. I - i �, _ FIREPLACE I I ;I _ 'i .� FRYO TGR _,( Iw_ _ - �� FURNACE 1 I----_ )I- :_`.----',1_-----.._ -1_— 1 -'• --11. f I- I. ... •I 1_. .. I '1 GENERATOR .-. --- -- I �R: �: GRILLE _. _ 1 II II_�_. I 1 I- I _I 1L.y . INFRARED HEATER -�. I �I 'i I _I_ I-._-I I ! LABORATORY COCKS . I • :I I. m1 , 'I I— i II t. ` il- OVEN AIRUNIt I_ _ I 'I *`1_ ' - 1 _ L_ 1 iI -- .POOL II EI ,. --t I ii��,I _'L- rl _ -I l_ ''L..:...: OVEN , = — POOL HEATER I-,_.__._ I h I ILA iT_ s ' ! 41( G il. 1ROOM 1 SPACE HEATER L�-r El 1 `,1_."..i 1-~ 1 _( 1 1 I !ROOF TOP UNIT L-_-I I II II-- ,i I ---.II—_ I I II TEST UNIT HEATER I. . _ _ ' r r lr 1. �_' UNVENTED ROOM HEATER (— I I I I I _ E (I l'" WATER HEATERI ;I. I__ I OTHER I .�.. I 4 -r~-w--� "�` `- INSURANCE COVERAGE I have a current liability insurance policy.or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L OTHER TYPE INDEMNITY 117 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 ® 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 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 compll ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. jJ L� � vM TEPHEN A.WINSLOW 1 LICENSE# 12298 t SIGNATURE PLUMBER-GASFITTER NAME S .__.._..._.__.,.�m. MP E .I MGF O JP D JGF O LPGI LI CORPORATION r-/-# 3281 C PARTNERSHIP E7# i LLC D#—I� COMPANY NAMErrEF WINSLOW PLUMBING&HEATING --1ADDRESS 8 REARDON CIRCLE STATE MA 'ZIP 02664 TEL 508-394-7778 CITY SOUTH YARMOUTH-+ H J --..-•-W- �_..� AX 508-394-8256�,I CELL(N/A�� ' F I EMAIL accountsplyable@efwinslow.co T v_ _. Office of Investigations Al if 600 Washington Street ti�-:. Boston,MA 02111 1 '"T www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers 4Unlicant Information • "� Please Print Legibly Ja ,^me(Business/Organization/Individual)•1.•'c .W,,.Stow OUP terecj ttat-inq_ Sddress: k.?oa ievl C,r>i ._ �ity/State/Zip: Sooily\ `icr„-,c),,-l•, 1,-(A- Phone#: '5OI-399-11'77 sre you an employer?Check the appropriate box: NI am a employer with 70 4.0 I erna general contractor and I Type of project(required): • employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 0 I am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working[,for me in any capacity. workers'comp.insurance. 0 [No workers'comp.insurance 5. 0 We are a corporation and its 9' Building addition required.] officers have exercised their 10.0 Electrical repairs or additions ❑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 insurance required.]t employees.[No workers' 12 0 Roof repairs comp.insurance required.] 13.0 Other '-N ny 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 antractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. tm an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site Formation.surance Company Name: (lrfp\,1 ti,•4110.-A 2L el t Otgw e licy#or Self-ins.Lie.#: Ial •� �^ Expiration Date: (—[— ?oil b SiteAddr'ess:D.3 Cr3nnrv‘cwly. CLA 11-t, Al el C623 , NI City/State/Zip: Oa'-i b? ttach a.copy of the workers'compensation policy declaration page(showing the policy number and expiration date). tikure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a re 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 'up to$250.00 a ddo against the violator.Be advised at a copy of this statement may be forwarded to the Office of vestigations�h5f a DIA for insurapeoverage veri(tcon to hereby certify ens a' penalties o p jury that the information provided above is true and correct. pnatuYa / �,r^ Date: la)3 i 1 ROI A lone#: Si' •Th-'777x �/ 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):• I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other • Contact Pi,son: Phone#: