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Home My WebLink AboutBLDP&G-18-006874 Pe, C erne,a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK l Off CITY I .,,,5 f t 7H _....j MA DATE ii // �I PERMIT#/ �' 45"71/ JOBSITE ADDRESS [ t 11�_.t9/eH 0 .N _�4? OWNER'S NAME f I '/7 it s_.] P OWNER ADDRESS w _ J .�=:. _ «.� . 1 TEL I.7 L.9333 - .1 .3 ,3 FAX ' TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL i-1 RESIDENTIAL N PRINT _ I CLEARLY NEW:Ill RENOVATION:L1 REPLACEMENT:I PLANS SUBMITTED: YES 11 N0m FIXTURES 1- FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ___, ._ __ CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM 1 DEDICATED GAS/OIL/SAND SYSTEM r_ _ , l DEDICATED GREASE SYSTEM 1 DEDICATED GRAY WATER SYSTEM i I 1 I DEDICATED WATER RECYCLE SYSTEM I I__ I DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN - INTERCEPTOR(INTERIOR) L KITCHEN SINK LAVATORY . ROOF DRAIN ! L_ SHOWER STALL i SERVICE 1 MOP SINK TOILET i r URINAL I ' �l WASHING MACHINE CONNECTION � I I WATER HEATER ALL TYPES / - I WATER PIPING _ ).f OTHER I f - CA ! i 1 I i I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ri NO ' IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I ` OTHER TYPE OF INDEMNITY IT 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 1 I AGENT I 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 tru-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 corn m•nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. pp //` _ __ ,.illy,, 6� �'/LfK/ PLUMBER'S NAME I STEPHEN A WINSLOW I LICENSE#f 12298 SIGNATURE MP[1 JP; J CORPORATIONP1# 3281C .. PARTNERSHIPS#[ _4 _'LLCI #! _____-I COMPANY NAME' E F WINSLOW I ADDRESS 18 REARDON CIRCLE . _. . ,1 CITY I SOUTH YARMOUTH j STATE I MA ? ZIP 02664 TEL}508 394 7778 FAX 1508 394 8256 1 CELL 'EMAIL I ACCOUNTSPAYABLE EFWISNLOW COM Dee r/fir ie sg coi dnagg!rb agAlea nES 'M Office of 1r vest1.cgdor. ` `'IMOM " 600 Waslagngtord St'reed Boston,MA 02117 • wwwomesigovidig Workers' Co:tpennsatioml Insurance Arnriamito Bun dens/Contraetors/J lecefriela ndlig tubers A Iliea,r.t llraform>g::ti®:o JPIease Paint Legibly • Name(Business/Organization/Individual): E 4c.tivfir,5 1 Qtthmto cv-Ic L z ok.. Qs... 1'i • • Address: ' (4 uf, C a 1Q City/State/Zip: Sos Sih \f c�r- css C-kPr Phone#: SUS- 3c14 1`171 • Are you an employer?Check the appropriate box: Type of project(required): 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.x 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g• [l Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 1.❑ I am a homeowner doing all work right of exemption per MCI 11,0 Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs , : insurance required.]t employees.[No workers' 13.0 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. :ontractop 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 niy employees. Below is the policy and job site r`'ormation. ltsuranceCompanyName: P"`lY(}:� ' (`A•Jk-uo.A Scwc.A. Cofin"riLj olicy#or Self-ins.Lie.#: I B A- Expiration Date: ^ aDl') )b Site Address:, 3 Co nn vkev)wh o-l 11-1. /k J ) elne36. I \\ City/State/Zip: O `6(e .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 Ma 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 Pup to$250.00 a da against the violator. Be advised that a copy of this statement may be forwarded to the Office of tvestigations the DIA for insurarpe”overage verif(aion. do hereby cert un e airs an penalties o pe jury that the inforraation provided above is true and correct. ignato • r Date: 1•ot_ 3 l al'7 6 hone#: ° �, 3"1`�- 777X Official use only. Do not write in this area,to be completed by city or town official • City or Town; Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ° Contact Person: Phone#: MASSACHUSETTS L MFORM'APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK y-,K Tm f' CITY ::. .SD if7A' 76Z�i._.e.u,T4/.. i MA DATE 5/q1/( . I PERMIT#./644/..� "C� �y JOBSITE ADDRESS: zi /.1.8, y/. (_fal OWNER'S NAME ' .0 f f OWNER ADDRESS ...... �..__...:....._ .. I TEL j 7 6.� .. -33 FAX, _: TYPE OR OCCUPANCY TYPE COMMERCIAL' I EDUCATIONAL ,:j RESIDENTIAL CLEARLY NEW:' I RENOVATION: REPLACEMENT:'$] PLANS SUBMITTED: YES-._1 NOEL( APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I 1. 1 I I: I• I. _1 I — I l i _ !'_-�__- --- 1 •_•._..I_. .._.I _... ;_ ' . ;. • i I_ ._ ..__! yl. BOOSTER i• ..,�..� _ CONVERSION BURNER '-..... 1:w�w__ M._--...1; -- _J .. ,. 1 .... .....__..J _.. _1, .-I -- ___..1I , ` �I COOK STOVE ;,ww...,_..1,. ._.! 1«.-_.._I . ..._,....J I. I I' . . _I DIRECT VENT HEATER ,- 1 I. I' I._ I _.,_...I J _. ..1 _I-----_s DRYER 1 i -.1-7ii . €: ._:3 ;% ' �I 1. 1 l FIREPLACE ,,.. ..(_.•. J 1 i _ _.I -I -- FRYOLATOR i I• _. . . - t 1' _ _ i _nn.i J -{< FURNACE . .r«,w.w,.._.1�. -„.,_�,...,.,.,�,..,« i��_..«..1 I _ I 1' ,.�.,,.T._.I GENERATOR7.a ; w :: , I 7-•4• GRILLE I I._ j 1: 1 ; I .... _.... ---... INFRARED HEATER _._ .LABORATORY COCKS �. „,.,„ If.w.. :. 1.______I ,w - : .,_,.•:: .I..,:..„,_.�` j.� -,..,,,,,,,1. _ i MAKEUP AIR UNIT L. `.....,_.__I, ..1•_._.....j, I _.1 I _I', _I,�_ 1. s. I I i OVEN I _........ I - t POOL HEATER i i• I i;_.� I ` . ._ _ --- ROOM I SPACE HEATER ......._...}, ' ._.._....-._, f: ..:.::..I 1--�- 1 ROOF TOP UNIT I:.._.:....,... I. I I' 1 i I_,.•...,...I. :-_ I. I I I ,.,. , 1 w_rw I TEST i I - 4 l I._.,„,1 - . �. • • UNIT HEATER i•_ I! ._._.. I' : -w-..,_3 _ . . _ ...... UNVENTED ROOM HEATER i _I. . .. ' ..1; 1 .1', I 1 I WATER HEATER • • _ .._ 1 OTHER I F 1 . . . I_ I I:.. I' f: . I I,_____11___._UI'�..:...i_'; _1 .«_.._i t _ - --:_R„_ m„ _ _ .._... ..._._..__..... .. . I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1.41 NO '.J I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ..-4.„1 OTHER TYPE INDEMNITY ,I BOND U.,n.,1 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 1 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 comp nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L r/llt4 PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE#.12298 �£ SIGNATURE •. - •• MP._.;,..1. MGF.,._J JP 2) JGF:_j LPGI _LiCORPORATION•„d#,3281C- II PARTNERSHIP.,,J _.# I LLC #. 1 • COMPANY NAME: E F WINSLOW PLUMBING&HEATING I ADDRESS:8 REARDON CIRCLE t CITY SOUTH YARMOUTH i' STATE i MA `ZIP i 02664 [TEL'508 394 7778 , I FAX'508 394 8256 I CELL N/A 'EMAIL accountspayable aeefwinslow.com 6 if, a ti__ '1°6 Depargmeigt of inaggstrgag Alccffaeer rs '••••, Office of Investigations } 600 Washington a Streeg r 'osgorg,MA 02111 WWW inas&gov/d ' Workers' Coll pensation Insurance Affidavit: aailderes/ComtractousfElectriciains/Pl4, bars Alp>plicant Information Please Print Legibly .• Name(Business/Organization/Individual): E.•`•W Q(tly i ieic (31 k l ett. Address: (Leo w City/State/Zip: Soa Av'N Wt'w=c,,,011 MPc Phone#: '50S- Are you an employer?Check the appropriate box: Type of project(required): am a employer with "70 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ®New construction :.❑ 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 required.] officers have exercised their 10.0Electrical repairs or additions i.❑ I am a homeowner doing all work right of exemption per MGL MO❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.n Roof repairs . : insurance required.]t employees.[No workers' 13.[]Other comp.insurance required.] lny 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. um an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site r0rmldtl0n.isurance Company Name: krt):.,.s \-)kl AI `c— ,rt/,rr&. C eakfiLl olicy#or Self-ins.Lic.#: \S 'I A- Expiration Date: k—] '• )b Site Address; C3rtnoekefi 1 wP 0-1 Th A-1 Ct(R3\ E 11'11 City/State/Zip: (, to 2 .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 advisedat a copy of this statement may be forwarded to the Office of tvestigations the DIA for insurapeeloverage veri tca1on. do hereby certifi,un e e sins an4 penalties o pe jury that the information provided above is true and correct. ignatu3 • ( / r Date: (oi_ t a®L s6 hone#: ,51Y4• 1`i '777b' 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#: