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Home My WebLink AboutBLDP&G-20-006393 .tt' 527 Y- J, - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -.te{ga a� v ' ` t ,�,. �^ CITY 1 C.l I n)41 1 MA DATE 16 J-7,2t 2I)I PERMIT#/,�->/' 3k "Ce r� JOBSITE ADDRESS 12F1 None- AV OWNERS NAME_DAME I Aimay_______ POWNER ADDRESS ,� trne ____ ___,.___ __ ._._ TEL 9U - 25B OiIFAX __.: TYPE OR OCCUPANCY TYPE COMMERCIAL LI EDUCATIONAL El RESIDENTIAL,. PRINT CLEARLY NEW:® RENOVATION:El REPLACEMENT;L PLANS SUBMITTED: YES El NOD FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE ' 1 1I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM r DEDICATED GREASE SYSTEM MN _ ;��;®�ME ME;Mil DEDICATED GRAY WATER SYSTEM i DEDICATED WATER RECYCLE SYSTEM I. DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER INTERCEPTOR(INTERIOR) WMW!uu$IIIIIIEI'IR 111.MIN M'NEM'MN'' NUR ,11111 EN LAVATORY SHOWER STALL II II KITCHEN SINK =1111111111111111111111111111111 TOILETSERVICE/MOP SINK III 1 URINAL WASHING MACHINE CONNECTION I 1 WATER HEATER ALL TYPES 111111111.11111111111111111111111.1111111.111[ III, II II RIR WATER PIPING MI _ ', OTHER 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ] NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY n OTHER TYPE OF INDEMNITY 0 BOND TI 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 [T AGENT Li 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 r to to the b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co li wit II ertine proyisioryof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r ,-• `, PLUMBER'S NAME[STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MPO JPD CORPORATION # 3281C PARTNERSHIP®# ,LLC®# . COMPANY NAME[.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 1508-394-8256 I CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM ZWif (,QC( Lib • • The Commonwealth of Massachusetts ' Department of Industrial Accidents 1`--' f- Office of Investigations _ti 3. os�la ' Lafayette City Center ,na•- �"�Y'of 2 Avenue de Lafayette,Boston,MA 02111-1750 u 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): 1.0 I am a employer with 90 employees(full and/ 5. ❑Retail 2.❑ or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 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]** 4.❑ We are a non-profit organization,staffed by volunteers, 11.❑Health Care with no employees. [No workers' comp.insurance req.] 12.0 Other *Any 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 • i the?Tins a and penalties of perjury that the information provided above is true and correct. Signature:t.,� "/y G(/----/".— Date: 01/02/2020 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): 1fBoard of Health 2.D Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: • _ -s.J oIt527 bO 450 , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • ti- K-t: 1_f=S' CITY .044.1 _ I MA DATE b`22 200 I PERMIT# /'I�DI -Sle• L✓ JOBSIT ADDRESS 13c)nir e A\j .. I OWNER'S NAME DkiTu11 1 GOWNER ADDRESS (1010 ].,___._,____„_.______.__.__ TE4, O IB.(T iFA TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL LI RESIDENTIAL PRINT CLEARLY NEW:(_ i RENOVATION:0i REPLACEMENT:X PLANS SUBMITTED: YES LI NOD APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ice' I _ [-- "(a 'l - �J _ -.._ --�I t l _ BOOSTER _ � � CONVERSION BURNER STOVE NEMI D ROECT VENT HEATER I I i.____I I II iI- DRYER FIREPLACE 111111111111111 Elk SO iliiiIIMM XII. FRYOLATOR -DIMAINCIIIIIIIIIMIM I - FURNACEsawn 5 � _' r W�� INK GRILLEGENERATOR f I�;[�f [ -� I 1- INFRARED HEATER ...r LABORATORY COCKS i OVEN _ MAKEUP AIR UNIT r u i -__ - 1---,-___ - 1 ME ME 1—I POOL HEATER �,I_ '„ w I _ _ —I ROOM I SPACE HEATER � �( —�- �(�, —1I. i� ROOF TOP UNIT I l ---11- 11 :: . , _ , 11-_, _ i - ,if-- ... TEST I UNIT HEATER I I i ,._.- UNVENTED ROOM HEATER ' I WATER HEATER _ _ �- �- OTHER — ( I f o. 'Mimi Mill11---7M--- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ['I NO I_ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY ® 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 r--1 AGENT r 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 b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliant a?mine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • !/ PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE#f298 SIGNATURE MP 11 MGF El JP D JGF® LPG!® CORPORATION Q# 3281C PARTNERSHIP®# _J LLC[# _ y COMPANY NAME:[E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256-1 CELL NIA EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents r�. if Office of Investigations ` 1 Lafayette City Center l 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): 1.0 I am a employer with 90 employees (full and/ 5. ❑Retail or part-time).* 2.❑ I am a sole proprietor or partnership and have no 6. ❑Restaurant/Bar/Eating Establishment 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]** 4.❑ We are a non-profit organization,staffed by volunteers, 11.[I Health Care with no employees. [No workers' comp.insurance req.] 12.0 Other *My applicant that checks box 111 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.#1909AExpiration 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 ins and penalties of pedury that the information provided above is true and correct. Signature: ^� �..� 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 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia