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HomeMy WebLinkAboutBLDP&G-17-003475 -1\ I111ASSACMUSET TS t 6NIFOREll1 APPL:CA`a?ON O}R A PERivi i'TO PERFORM PI UtlillBlNG 1,010R't; ' a CITY , S cr a.0 J/., MA DATE - z PERMIT# ' 7 V 7 JOBSITE ADDRESS 11,?_‘...„. .,) v 3�C cu!,..,.:C,-, �, J c OWNER'S NAME L, ._....__........__._ Il OWNER ADDRESS r ' TELLji 2,, ,y, /yy3FAX TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL �j RESIDENTIAL rg PRINT CLEARLY NEW:D RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES Q N00 FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I 1.__e L r I I -I CROSS CONNECTION DEVICE _ r I I _�'® .-- NSIInui DEDICATED SPECIAL WASTE SYSTEMMEM I- I , i I~ 'f (- l DEDICATED GAS/OIUSAND SYSTEM I j . I 1 I I I. I 1 [-i DEDICATED GREASE SYSTEM '. IM _ DEDICATED GRAY WATER SYSTEM I I _ I I_ I Ji l `1,_ I• =_-, 1 IISIIIMIIIII DEDICATED WATER RECYCLE SYSTEM I.__, .1` ! I ( F - - r [ - , ••-( t I DISHWASHER 1 I ._ I .._ 1 I - r- I DRINKING FOUNTAIN i r- aI __ I---1, 1( '.r r Tr 'I, ®r-- FOOD DISPOSER ! ,_ I �I I) I ®r---'( SIN KININI FLOOR 1 AREA DRAIN FMMIIIIIIIIIMFINIIIINTNIIIIIIIIIIIIMIIINNINIIIIIIINIIIIIIIENIIIINII INTERCEPTOR(INTERIOR I-_ MMANIME- i� M f III KITCHEN SINK [ C I ( LAVATORY Man r _ 1 r` F - �-® � ROOF DRAIN i - .. � I _ ®I ��I 101 SHOWER STALL [> I ._,__,: � ( INC,- n^ ® .� 1101 SERVICE/MOP SINK I1. ... . INIEMININIIIINIMISIMINIIIIIMPINEIMEINSEMIN TOILET illiliMININIMMI MMIIIIIIIIMINIIIII URINAL IMINIMINIIEM ���t �I� \ WASHING MACHINE CONNECTIONBINIIINNIF-lnli ! ' �~ - IN WATER HEATER ALL TYPES �1 ._ 1 I WATER PIPING i ��� OTHER [ I. ® mmi !I I -I - --Ii#ANNANKIIN I 1 I I {_ r i1: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE OF 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 E3 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 tr e 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 co fiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LPTEPHEN A WINSLOW . ,..,,.,_,.,-_j LICENSE# 1229$.,._ + SIGNATURE MPO JPO CORPORATION ,t # 3281C iPARTNERSHIP. # w COMPANY NAME EE F WINSLOW PLUMBING&HEATING -]ADDRESS 8 REARDON CIRCLE ,...-..�� ____________ CITY DUTHYARMOUTH 1 STATE I -MA ZIP 02664 ` TEL 508 394 7778 i EMAIL accounts a able efwinslow com v FAX 508394 8256 ; CELL NIA Y.. w f 4t L1G . LR i�f . f 7.; e s.U'L?.a r l,�`e�:�' � NJ "Cr d l�"t;o - _ �'i • 'ill- .o 27.30,5e0n2 IVA 02111 ' wwwo mezlilod Wor&&rs' cCo tpenanthern HRISTairela. e • is &&vnto i taIlderes/Contreectoreo!EIlect>sIld@ng i bra*ergs pitollicant 1fniftbruatn®n g Phase P Ant 7 eclbiy .• aim(Business/Organization/Individual): E^�•yv„, S,�vA1 Q(V�a(0iJie A IAg.�"� e.) 1frte ddress: a.,,,,,a c rr t.q._ ity/StateIZip: Soo k',e‘ MPr Phone#: '50S-3M 1T1v2 • 'e you an employer?Check the appropriate box: Type of project(required): I am a employer with 70 4. ❑ I am a general contractor and I 6. ®New construction employees(full and/or part-time).* have hired the sub-contractors I am a sole proprietor or partner- listed on the attached sheet.$ 7• ®Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ 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 MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]I employees.[No workers' 13.0 Other comp.insurance required.] ty applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors arldtheir workers'comp.policy information. m an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site oTmlltion. :urance Company Name: ,„3 (`-kv'Iry etA ^ r(1.rC,i n C.e,. Cq °iy licy#or Self-ins.Lic.#: }$ I A Expiration Date: C,-1 — apt-) b Site Address:,. Corvnrheli v alTh A04.1 C S '1A 1"\11, City/State/Zip: 6 '4 67 :tech a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). , inure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a ie 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 da against the violator. Be advised t at a copy of this statement may be forwarded to the Office of vestigations o_the DIA for instxraneoverage veri caion. do hereby certify un e e.ains anApenalties o f�pe jug that the information provided above is true and correct. ignatu • lt.� Date: t o�.� i 9,0 L 6 hone#: .c •314- "777X Official use only. Do not write to 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#: r - r MASSACHUSETTS UNIFORM'APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - =s r% .....�, CITY Brs/T rei�1'!D.ftg.,r ...,•,,,......1 MA DATE /z -?,g-/G jPERMIT# J 1 9-/7- ,� JOBSITE ADDRESS: `f wl -9 L�c,1 1t.71' f � OWNER'S NAME tT `//Yi.. .. iA, eel/r`c. .,. .G _ OWNER ADDRESS '. if ;TEL1 f ._yJyyFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL'41 PRINT CLEARLY NEW:'..,,.r1. RENOVATION: ,._1 REPLACEMENT: 4 PLANS SUBMITTED: YES I...__x NO_._-? APPLIANCES 7. FLOORS--• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ry I..__._._3 i j ..._.. .__._._, _._... , _........_ • BOOSTER ,J,....,..,...a. j i.._ ..._1 _ _ _I_..... 1 --., ._...._1 CONVERSION BURNER ; _._. j...._..._I,....._..._. ._.._.. __ w.COOK STOVE _ _€ . . __A _....,....1_ °a..'_f DIRECT VENT HEATER _ ...__.1 - i. __ I i°. _ DRYER i .....f!...._1:. f,,..._.J 1' FIREPLACE I_ _ ',:. _m` f;__� .FRYOLATOR f_.._. r -I 1 _ I FURNACE J .� _.. r` J i I -- .-.:: ! I i I 1 GENERATOR _...._. f .,.,,.., GRILLE ;^ INFRARED HEATER • s. '' r I i LABORATORY COCKS 1:,_r,.._.I.�.... . _ _ .„1 ,.- .. MAKEUP AIR UNIT 1.—; __ , .. __.,J._ I __ J _, „,),_......,-.1 .-..,., ._ OVEN 1 I„ r I l., I I I I I ;. I I; I, .. POOL HEATER (._J: ! ' Cb ROOM I SPACE HEATER ,. .,..___I I •s _-.-_.a, I i__._-t ' .. -.I . .._ i 4! � N. ROOF TOP UNIT , .:.._ f. t: f. _ t. . I; 1, .I i_ ._.i 1 TEST EST i I i I. -. ._..J , . , I i.. - _. Ix) UNIT HEATER ' r- f' a J • UNVENTED ROOM HEATER 3' I:_ 1;. I I i —I- I . . . I .. .I .. .. I - . � . . WATER HEATER...... ..... ........... ........... ._.�G_.J ...I ::. r I_�.I _ _.� .._i�� .... -._... �` ~...,J OTHER ,__. ._ . ..._ . .__... . ...1 .. . ... ... . ...I. €... ..... . _...i; _..._,.......1 _...I . ......j........ f.__.._.1... --.1,_ _I € __...i I 1. I,II i = s I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I'i-I NO 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 ` 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 __I 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 nd 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 ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 _t SI NATURE MP..�.1 MGF.„....1JP .;_i JGF:J LPG! CORPORATION•/1#:3281C 1 PARTNERSHIP .,.�:# I LLC �- .#. I COMPANY NAME: E F WINSLOW PLUMBING&HEATING I ADDRESS!8 REARDON CIRCLE i CITY SOUTH YARMOUTH I STATE i. MA (ZIP i 02664 ITEL 508 394 7778 I FAX:508 394 8256 1 CELL:N/A !EMAIL accounts arable a©efwinslow.com _ , 6 qôrf V 1 . CpCdr'mC12g Of itiCIM;�prr'c1V 1'a;:ClcreitiS Office of Ittl'esllgl ioils : ; 500 WtishlfrIgtom&Peea * "' A. 3vst©kg91i t27L117 Wor&m's' <C rucapengztlora[nauregura ce Affndsvit: lkleres/Corgreaeto r°a/i lectrricnan 1i 1>1tra k ea•o AToTolicant haSibrimation ` ?lease?legit 1Ledbliv Name(Business/Organization/Individual): E°4•WrsSI 0v7 QLi .IO;Jtej 4_ e.o�t-, G. VIC 0 / Address: F (4 t., CIrd.Q _ City/State/Zip: o,1 '/o crw-,cr M Phone#: S- 3c14-11`7cq Are you an employer?Check the appropriate box: Type of project(required): I am a employer with /O 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors !.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑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•0Electrical repairs or additions required.] officers have exercised their I.El I am a homeowner doing all workrightexemption of exem lion per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c, 152,§1(4),and we have no 12.11 Roof repairs insurance required.]t employees,[No workers' 13.1E1 Other comp. insurance required.] 1ny 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. Lim an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site rormdtion. tsurance Company Name: c,I\YIM,.,-•3 rl`l 0--)1 ,3_17rqurtit,et CQ,. C ov,"eavili olicy#or Self-ins,Lic.#: 1 S a l A' • Expiration Date: k—t aepl—r AI Site Address: 3 C+v,rtanw�'R-1,Tt Aki`0..1 e s t I'MI City/State/Zip: Or)Li 67 .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 no 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 t at a copy of this statement may be forwarded to the Office of • tvestigations(o`f the DIA for insura iee overage veri Gaon. do hereby certify on,e-: e sins an%penalties o jury that the information provided above is true and correct, 7 i• attire• A,r Date: ( 131 l aoL -' lippr-hone#: ,ci •3T]- 777E 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#: