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Home My WebLink AboutBLDP&G-17-002161 _-.: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 7 j=is' CITY f ,, f' 'T MA DATE L 1PERMIT#/ 49P-17-0d,:g/4'/ 4) JOBSITE ADDRESS : i 1i.L ,QJ n, d i OWNER'S NAME �.,==,_ OWNER ADDRESS TELL 1 FAX L -i TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL E RESIDENTIAL C PRINT CLEARLY NEW:fj RENOVATION:0 REPLACEMENT:p PLANS SUBMITTED: YES E- NO % FIXTURES 1 FLOOR-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE �. t . .- I art , .numma. 1 '- DEDICATED SPECIAL WASTE SYSTEM _____ M DEDICATED GAS/OIL/SAND SYSTEM MINI .IIITEMMII DISHWASHER Fr--AISIMINSINIMIIIMMIfflignitilftiMMUMNIMM DRINKING INTERCEPTOR(INTERIOR) gr,77.1E-1:::::217.:ilillar.---,111 ,121111111= O D•A NMI ,f ':l t._.. 'MI.,-,.. -:I•111MMIIIIIIMISSI___ .. . ngti TOILET �T-.'� ®i�i ��-1�:.,,. ,:1 �� SERVICE 1 MOP SINK [ � - URINAL s E. :- _ ANIMINIMMININ WASHING MACHINE CONNECTION 1V _'ITS ; I [1j� WATER HEATER ALL TYPES ._----1—7 ! I. - 7 � WATER PIPING ,_ IvF7:("�' -- OTHER - - ._��-(—,-_ ;( �1 'f _I I� ®I_ . _ ---- L�--_•.'if . :'1 `WINr 11— I--1� - --;, r_ 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 1 OTHER TYPE OF INDEMNITY L BOND EA 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 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 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 com nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, Wit- 14h4t,,,P,"44} PLUMBER'S NAME'STEPHEN A.WINSLOW _ __ J LICENSE# 12298 ( SIGNATURE MPLI JPD CORPORATIOND# 3281C i PARTNERSHIP D#T 'LLCD# . COMPANY NAME LEF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH _ I STATE MA ZIP 02664 _ u TEL 508-394-7778 _ j FAX 508-394-8256_ CELL I NIA -1 cco EMAIL a� ounts� able@efwinslow.com mTi Department ofdndustrialAccutenes -_l� h`t Office of Investigations - =ilnil_y_ 600 Washington Street =i}if= Boston,MA 02111 • www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information C t� Please Print Legibly Name(Business/Organization/Individual):e,c•W:✓v5'ow `Q(�,n6O,✓rc� L 0<.0.\- ce.)I'm. Address: ' (4oeri vl ClrcI — 0 City/State/Zip: Sos-c 'lc' \-1^ t4Pr Phone#: `5Ob-3c14-1'17C1 • Are you an employer?Check the appropriate box: Type of project(required): ,.. I am a employer with '70 4. 0 I am a general contractor and I 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors !.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. 9. ❑Building addition [No workers'comp.insurance 5. 0 We are a corporation and its 10.0Electrical repairs or additions required.] officers have exercised their I.❑I am.a homeowner doing all workrightexemption of exem tion per MGL 11.❑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.] my applicant that checks hiss 01 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. hm an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site 1 iformation. /� - � I 1 tsurance Company Name: Arlr0•..s ( 1J 1'ti 0.j1 ..5 1150`u''t Ce._ uV `✓��`) olicy#or Self-ins,Lic.#: 1' AI A' Expiration Date: 1—I- ant-7 )b Site Address: 3 GAr"\ort\.1'`-ee.-'i As 1 CN2A 11 City/State/Zip: 6,�467 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure 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 da a ainst the violator. Be advised at a copy of this statement maybe forwarded to the Office of tvestigations the DIA for insurat3eefoverage veri ion. do hereby certify un s an penalties of pe jury that the information provided above is true and correct. ianatut: / l L_/� Date: (DI 3 I I c't0(5'^ hone#: .cra.3c 777g l/ 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 UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ;ci-70-fg- CITY #----._... .f ! _Z -__=�-...._.. .,......�. MA DATE lit /�? i--) I PERMIT# I'�� P--/ 7 O f / r`n JOBStTE ADDRESS?el /e7/42 y Ø77 1 _OWNER'S NAME ,��,%y/c( J * 4 ' G OWNER ADDRESS 1 t TYPE OR OCCUPANCY TYPE COMMERCIAL y PRINT ( ,� EDUCATIONAL �� RESIDENTIAL CLEARLY NEW:Ell RENOVATION: [ j REPLACEMENT: •-'.' PLANS SUBMITTED: YES Ej No - APPLIANCES 7. FLOORS-4 BSM 1 2 3 4 5 . 6 7 8 9 10 11 12 13 14 .,,,j BOILER 1. I....� _... I�• .. l.. 1 _. II_ ,a. II ll ,!_ _ i _ i! :i. i �` BOOSTER �_ I. i 1.. . 1- �. .11--...— *I_.._.,_;,1_,_..;I II—' ,f_ . �i_- . . . f1---- . ;iT I[.` 'ii —1 +..•J. vi'`�J..Jv .-' T..ar.__.N. 1u_-_.. ti.>•�.._+.__ iJQ_.z- '� ,i .. i.rs ..fir J ,.� V- CONVERSION BURNER :=i L_ .7 C _ _ i `" COOK STOVE 1_ . ;I..--- -Ir. -- -i j _:1_ — _1..-=.--1L �_. 17'7 ,1. '1�.-. i 1----- . I I,.. all .171 DIRECT VENT HEATER I_T_ -11-•---_-.i 1__ -.l i. .- .'',;I_ _ . _ 1- . ., I _ .r,l _ -. 117 I----- .-•,1-_ - Jr. _ ._Il.-.. .1 . .- __II_ DRYER I . 1. . .. 1I [... i.-__ .:I. .__.._ ��_....1l i_. - i _ w. +._.._�/it,..... I. i 7-1i.. 1i--- ----1 • FIREPLACE . I _. �1 - _._1' .- ._i:•_ i----_,1-= i FRYOLATOR L. ► I, I ,._ __ - Jr... 7.--II.."- �__.I. i1..'_.- 1.I._____ ,I-' __ I—_ .' I_ _ . ' FURNACE i -�(---- ; Ii ' C 1 :Ir_ . ry';1.`-__�i--- __, 1___.7 1---.i .11-- fi €1777. GENERATOR ��_�.__ 1:..:�. .. � : l �..�_,�.-- �-E, _..-)I..._ ..1. . .--•-�;1 � ----�-..: ;� .--- � 1 t li. � ,_ I 1 .i_ GRILLE I�..-_ ( II : � __... i._....�1 .�...:;�..�_- +--- _-- 1• . I _ . •I � .. .l 1_�.�-� INFRARED HEATER I_ 1...... .•-, I , • i i__.._. :II. ______ I----..._. i_ 1. _.� iw :1_. `1 _. _._'I . LABORATORY COCKS • ,-4-----�: I ... ., 1 - -- 1—•---, ;_ _- ,�_ .__._1:_.�_._.,�i �.,�. .._ '�1 _..__ ��._. ,__..._ii-�.. I . _ .. `� ,_ ? MAKEUP AIR UNIT I_ _ 11 _.. 1_ (.� wi:l . . ;1:. !' . _.i1 i( ' . I. _. . _ :1 f7_-__-;i--�1`-` OVEN {.� —;f I- --.-i l_ .. I - -11.-_:.-.. -~ 1. . 1 ._ . )1�-7-i .--,1__- '1 ----. -i ...,>I-----1, POOL HEATER r I II . :I __I I : l. . . i{_...:_..'+I _ _f1 -,i—_- }1 :1- -i1- _ I_ . I . ROOM 1 SPACE HEATER i i ._TI i_.._ L - W 1__ - I_ I.. !I -' ly,:j i 11 I.,_ ROOF TOP UNIT _l 1r .i 1._.i i i.__ .f31.. J:1 II.. ;1_..J I�. _ 1 . V I .i fi (1__._ 11 TEST I.. _'i-"- 1- ,f---- .,�-�_._'•i.... i - -- ;1 ,1->�_�1�- -- . 1.- ....._,� - _:�1 t UNiT HEATER T- - - -- _ �_ . . ..�..._}.. h- ( -- .. UNVENTED ROOM HEATER I i 1..- ---rh_._ 'I ii— ,•i. - d _I �I. it i1 it. . 1[,__,. WATER HEATER �--ram_ i . ►I . . �i 3_._._..;1___.._,� . --�--, -�-�--.i:�1-r� l__ �.i . ._�i��i, . �: OTHER , I_`__. ._1 I_ -- . ' i_ . . .k.. H 1 .._ . �1. `1-.... . 'I _ . . i._. . ;I. . - , I_ __. •U_. _._.. . 11 -- - (1. . . i .,-,.,7---..„.-:::-...-.„-.,..:,-_,.:„.-.,:-.„" ,._.._:--. 1 -_ - i . ..11—..__.. I. -.. _...__7 __._._._ ._ I- Z'� .- __• _ I _- _--• KS - _ 1 ._..,............ ,...�,�. ,.,..�...y.._._._.. L: I. �,-.• -_: -.....7.,__ _- �i ._ _C_ _ - I . _ .._ i l - ?i . .. .1 _I I- .. .. `1,_ _ I' __I.__ _ 1'. r _w-... .... � rT- 1 .. .� .__.I ( -•rJ1ilJ._....+._vT, .�.,..aFr.. ,_. . 1 . . ... .._ ..-._.__.. ._. -... __ . _ I 'tT , Ir' --y-11 I. e '- L: l I I J11.t.T..S• Kf 1 .R►.:::3'.�. .'�:T,.->, INSURANCE COVERAGE I have a current liability insurance policy •or its substantial equivalent which meets the requirements of MGL. Ch, 142 YES El NO E I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY E 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 ED AGENT LJ 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 wDrk and installations performed under the permit Issued for this application will be in corn Hance with all Pertinent provision of the Massachusetts State P.umbing Code and Chapter 142 of the General Laws. /L42,424.0 PLUMBER-GASFITTER NAME ILTEPHEN A. WINSLOW I LICENSE #L12298 SIGNATURE MP J MGF D ,_P E.j JGF Ei LPGI rj CORPORATION 17# L3281C PARTNERSHIP # ....., LLC D# COMPANY NAME: EF WINSLOW PLUMBING & HEATING I ADDRESS Ei:Eki DON CIRCLE ;� CITY SOUTH YARh10UTH - STATE FFAT ZIP 02664 jTEL 508-394-7778 FAX 508-394-8256 CELL N/A !;ENTAIL accountspRable rc of iinslow,com . �/i /1- w___ Department of Industrial Accutents 1' =!l „AW.; Office of Investigations •=2i=.5 600 Washington Street `'i�1�= Boston,MA 02111 • www.mass.gov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information C f t Please(� Print Legibly Name(Business/Orggnanization/Individual):l�'c•W1 S{evl Q(Vsn6-w-tee 2 0tah✓ `e.31'n(• Address: ' 1�Ptrcien C itr1t; 0 City/State/Zip: Soo k v 'tct11,^cs.-In t-MPr Phone#: Oi-3`4-1`'7 I 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.t ?• 0 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 5.0 We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their t❑I am.a homeowner doing all work g exemptionper right of MGL 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' 13.0 Other comp.insurance required.] bay applicant that checks hox#1 must also fill out the section below showing their workers'compensation policy inforration. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lontmetors 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. isurance Company Name: (mil' Yp•.,s C*J k o.11 l -\f(.bttb.el C2 C o1 ti'tt1 olicy#or Self-ins.Lic.#: 1 S'Al Ar 1 Expiration Date: C,-1" and"-) lb Site Address:D3 is-an w-e°,-1 , y O'Ne3Ad> 1.;11 City/State/Zip: 0,.)4 Is? ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). . ailure 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 t•up to$250.00 a da a ainst the violator. Be advised t at a copy of this statement may be forwarded to the Office of tvestigationsi6IThe DIA for insuratpe€ttoverage veri aon. do hereby certify un e s an penalties o pe jury that the information provided above is true and correct. �a // Date: t of 3 I 1 aO i 8i^ hone#: cl,)1•:35`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#: