HomeMy WebLinkAboutBLDP&G-19-000730 Fa- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
' V.
CITY II,,, o t/7' zeac t a f Tf_f., _.._,j MA DATE I -3c 11 I PERMIT#f// '°'
JOBSITE ADDRESS y,4 6N. , 4eg ..., ?11 OWNER'S NAMEt P1j,t/6. �C,D?,.,/(7./f%
P OWNER ADDRESS I. 3
...fZ 1. E.g,,� _?.T3_y..... Ie ::1 TELI7u// / 1FAX1 �...,1
e �3c
TYPE OR OCCUPANCY TYPE COMMERCIAL IJ EDUCATIONAL Li RESIDENTIAL_ ]
PRINT
CLEARLY NEW:C„_I RENOVATION:El REPLACEMENT:V PLANS SUBMITTED: YES I-' NOI_l]
FIXTURES 1 FLOOR--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB —_____ -I I--
I ..__.._. I -- _ ..._..-( . __,f___- _ ± ...-._ ; I ,
CROSS CONNECTION DEVICE I r 1
DEDICATED SPECIAL WASTE SYSTEM 1 I
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM , 1 j I . I
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN 1
FOOD DISPOSER
1 1
FLOOR/AREA DRAIN 1 ._
INTERCEPTOR(INTERIOR) , 1 I 1 I
KITCHEN SINK '._ _
LAVATORY
ROOF DRAIN ( i
SHOWER STALL I I I , 1 r
.
SERVICE I MOP SINK . ..--{.w.._-I-
(_._ :._ i.. � , i Vim
TOILET I I I 1 i
URINAL I i.
WASHING MACHINE CONNECTION 1 I
WATER HEATER ALL TYPES / ' i
WATER PIPING
OTHER I I I
,
i ;
, I i t
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES I . NO I1
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1 OTHER TYPE OF INDEMNITY BOND I
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 fl AGENT [Ti
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application ar ue 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 c pliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -
PLUMBER'S NAME[STEPHEN A.WINSLOW LICENSE#j 12298 GNATURE
MP JP[ ] CORPORATION FT 3281C._.. PARTNERSHIP #� ��LLCLJ#I.. _ ,
COMPANY NAME! E F WINSLOW I ADDRESS 18 REARDON CIRCLE 1
CITY[SOUTH YARMOUTH __}STATE 1. MA ZIP 102664 1 TEL[508 394 7778 , u i
FAX 508 394 8256 'CELL �..vl EMAIL I ACCOUNTSPAYABLE@EFWISNLOW.COM y _ ����ATx_ i a, ,, _
.0
2
DePargraeW inagatinagAccggecnss
g r� 1, Office ofIrsvestig glom
41 600 Wahl gton&&Fee/
izttro
Boston MA 02111 •
12+4i WWWWP/is 'eS1odov/dii •
Workers' Con pox:sation Insurance ce Ai daunt:B lders/ConttreacterrsiEleelrenidaresinsanbers
A !leant Information Please Print Le 131 -
Name(Business/organization/individual): E W r (evo Qf V lo t, � ci_, i,e
Address: ' Qpo evt C cl
City/State/Zip: Soo ry'E‘ MP Phone#: '50S-Y1L!r 1f7
Are you an employer?Check the appropriate box: Type of project(required):
.„ I am a employer with "70 4. ❑ I am a general contractor and I 6. El New construction
employees(full and/or parttime).* have hired the sub-contractors
1.❑ I am a sole proprietor or partner- listed on the attached sheet,t 'l• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance, 9• ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
10.❑Electrical repairs or additions
required.] � � officers have exercised their
I.El I am a homeowner doing all work right of exemption per MGL 11,❑Plumbing repairs or additions
myself.[No workers'comp. o. 152,§1(4),and we have no 12,❑Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
4ny 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.
:ontractors that check this box must attached an additional sheet showing the name of the sub-contractors:and their workers'comp.policy information.
an employer that is providing workers'compensation insurancefornzy employees. Below is the policy and job site
rormddon.
tsurance Company Name: A y ( -ij �' �C� c‘tswytkvri }.
olicy#or Self-ins,Lie.#: \S i A • Expiration Date: —[ " au-)
)Site Address:,)3 G3MrvAasn J e Q )r . CG\ l 1•
` `\ City/State/Zip: O,)d-1 l 7
.ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
ne 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
f up to$250.00 a da against the violator. Be advised that a copy of this statement may be forwarded to the Office of
tvestigations the DIA for insurapeeloverage veri a ion.
do hereby cent un e e sins an ))penalties o pe jury that the information provided above is true and correct.
!gnat& • r Date: ( 1 3 t ao 1*�
hone#: ,c 0q• - 7 77X
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#:
E!.'dASSACHUSETTS UNIFORM AIaPLICA T ION FOR A PERMIT TO PERFORM GAS FITTING WORK
.E 7 E BilLr. CITY :S i'T� ',n 0, :j MA DATE 7-,'t:-26', f PERMIT# /30,,,7-194,710'
JOBSITE ADDRESS' �te 0 ,E OWNER'S NAME L , . W( cA? ti,✓_.,,
GOWNER ADDRESS ; • • J s XV r TEL 4)0 _T ;FAX
TYPE OR :_ et 730
PRINT OCCUPANCY TYPE COMMERCIAL',w•i EDUCATIONAL '„t RESIDENTIAL
CLEARLY NEW:J.J, RENOVATION:'»..-.f REPLACEMENT PLANS SUBMITTED: YES•_._4 NOi.J
APPLIANCES Z FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _�.I_..___
' I _!I i f =` I I:_,..__ F. j i f -_.- i—-- '
BOOSTER r-• ,4._.1:.----.,1_--.-
.._..._ _._._j E_._..._ -- : i - - -....- •' - - -
:
•
CONVERSION BURNER i i____I� _...-..f'..-_- ..._.^-I .. . ..,f i.- .. _..._! f` _2( I^ . .1_-_.J 1 M --
COOK STOVE 1 !. J F: -
I r.
DIRECT VENT HEATER i +_.�_. •.��:' j '• _____I:r-.... ._, _ii J
}
DRYER i �.1 . .I•
,. 1: j . ,l 1 _J I.,�.... i i
FIREPLACE ...... ..(`_ _ i _. I - -€ J.- s . I_ ,I ,....._..1 ,.....,. :_ . _M,f
FRYOLATOR _ _ ;; E_ .. .I-,-,..--,,I.,
.. r . ..- i
FURNACE I! t;_._ I' _.I. _. r jaf I_
GENERATOR ' -_ ` ; l I I f ..
GRILLE 1 ~` .-
3
INFRARED HEATER ` I I' _f .-_.i J I!� 1
LABORATORY COCKS I, i' ' _I J I w ri I
MAKEUP AIR UNIT J (�
OVEN >.� .:.�.... � .. I
POOL HEATER •I • • ! • I •• • .I---? % ..
I
ROOM 1 SPACE HEATER { - f;-----1:- f • _
. _.j it °
_
ROOF TOP UNIT . :,,
TEST • i"_._.__I_^__.. i 1: i, r f . ._ ._...
UNIT HEATER `. , I. ;' z: f • f.__ I: __.__~ I'- I . ._-1..--�-_,
UNVENTED ROOM HEATER i I'.. I:.. • I;-_.._ 1 1 . .. ... ;'. . ..I.._...._I_. .! 1 f___- _.•- .i
WATER HEATER .. _,..__.. _.__. •• C i, ' _ ..I _ i f i. 13 I ., I- I
_.I:-._- i._. :.__.: i,____..1;._.__ I
I1 _ _I`
.. ... -_
5 4 is
� ... ..i ...._---I•-___.__i 1_ .J -_._j j._...r..._I_._1--^----_
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IA NO u.-{
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ..,.i.J OTHER TYPE INDEMNITY ,J BONDmr
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 •„,,j AGENT i...
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 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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW i LICENSE# 12298 SIGNATURE
MP. MGF._1 JP _.-JJGF j LPGI s CORPORATION .id#:3281C 1 PARTNERSHIP ,•:# 1 LLC ...#.
COMPANY NAME: E F WINSLOW PLUMBING&HEATING J ADDRESS•8 REARDON CIRCLE
CITY SOUTH YARMOUTH I STATE MA II ZIP 102664 j TEL:508 394 7778 •I
f
FAX 1 508 394 8256 I CELL:N/A fi EMAILI accountsRa rLableea e.fwinslow.com
0
!' �fb
LRn
,. _ Dep s/meog oil ivaa grtatg Al ccirttedsva
=1: 'r Office of Iiiv '�t gigions .
600 WiftI:+ihagton Sfeeil
as D°✓ww m agov/dda
Workers'Coxape>lnssttionn Insurance . tr davit: lllers/CContractorrsil. 1ect ici:ins 'Ia .1lbers
Applicant Inforanatio r,, Please Print Legibly .
Name(Business/Organization/Individual): E,c• vv r,r 51 ow Q(V (j'w L .�� ce., j eit
• J
Address: (413eatIri C i m1
City/State/Zip: oa Ate Wr—cs.,k t-&Pc Phone#: 650S-Y 1`f P 13
Are you an employer?Check the appropriate box: Type of project(required):
,, I am a employer with -70 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
;.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. El Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. El We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
i.❑ I am'a homeowner doing all work right of exemption per MCI 11.❑Plumbing repairs or additions .
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
• :. insurance required.]t employees.[No workers' 13.111 Other
comp,insurance required.]
kny 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.
:ontractors that check this box must attached an additional sheet showing the name of the sub-contractors:and their workers'comp.policy information.
Ln an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1
formation. //��
tsurance Company Name: (�1Y •,,.s ckoi-i.io wet elCe_ Ctvv. ✓1
olicy#or Self-ins.Lie.#: \ I A • Expiration Date: C—1 — a°l"7
)b Site Address:,)3 Co(\Amoy)v a-11h Ala C k 1 I' 11 City/State/Zip: O,,Li 6 7
.ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). •
allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
ne 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
fup to$250.00 a day against the violator. Be advised t at a copy of this statement maybe forwarded to the Office of •
tvestigations the DIA for insurarpetoverage veri colon. r
do hereby eert can,e~ e ains an penalties o pe jury that the information provided above is true and correct.
ignatu i• r Date: i o_1 3 i 1 ao l i
hone#: •517 •31`i' '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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other .
Contact Person: Phone#:
.
1