HomeMy WebLinkAboutBLDP-19-000622 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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:711V S W CITY l \WWIAU W I MA DATE '7 !',LS I I ' I PERMIT#8/-4H9'wo&a+
JOBSITEADDRESS SA. W; I fin ut S, Yc rduJ Jh OWNER'S NAME ,[AAAA Hew 1 4-}
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P OWNER ADDRESS Si W1/4.+1r94• Wl-fr,rdfr 1,01151 TEL LialiE'jallFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NOD
FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 1 7 8 1 9 10 11 12 13 14
BATHTUB in
CROSS CONNECTION DEVICE 111DEDICATED SPECIAL WASTE SYSTEM _DEDICATED GASIOILISAND SYSTEMDEDICATED GREASE SYSTEM Saul
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM ��
DISHWASHER
DRINKING FOUNTAIN ---1-
FOOD DISPOSER IIIFLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) - r
ARE _
1111 '
KITCHEN SINK
LAVATORY
ROOF DRAIN _
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES MinOsi
WATER PIPING _ .ant_
OTHER r
III
111 _ OIL
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO ❑
y—, IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
N LIABILITY INSURANCE POLICY❑+ OTHER TYPE OF INDEMNITY 9 BOND 9
u OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
a Massachusetts General Laws,and that my signature on this permit application waives this requirement
cr CHECK ONE ONLY: OWNER ❑ AGENT 9
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are t 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 lance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /e/ s
'7' PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE
MPD JP CORPORATIOND# 3281C PARTNERSHIP❑# LLC Oft
COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
"cO CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 1
FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com
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Vin a it leVIIfI IfVI f Ir!LIMO.,J IIJIfoJNu1That aa,
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=-i— Department of Industrial Accidents
_milt= t Office oflnvestigations
CCM_ -.600 Washington Street•.,
'. ' Boston,MA 02111 '' t
..- . , www mass.gov/dia - • 1
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 1
Applicant Information c 1 Please Print Legibly
Name(Business/Ortganization/Individual): E,C.Wtr,S�OW Qlv,r.„0uno .& 41t0.Y- v' Ce.} Iel(.
Address: ' &etatrn Ci ie- d
City/State/Zip: Sou Ain (c'f'wts-Ain NA' Phone#: `VS- 3`19-1'175 N
Are you an employer?Check the appropriate box: Type of project(required):
Xam a employer with 70 4. 0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors v\
:.❑ 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 O
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition "(\
[No workers'comp.insurance 5. ❑ We area corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions c:;),S )4
1.❑ I am a homeowner doing all work right of exemption per MGL 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.]
thy 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.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation. //�� I
isurance Company Name: PT(Yp...7 t` u -uoA n fock n ct Ca,• e ll
olicy#or Self-ins.Lic.#: VS o.I A 9
1 1, Expiration Date: �—] � af31 /
we 4h A.t-e CFe3 yv4' I"n ti
>b Site Address:p2� � � City/State/Zip: Oai••I t,7 '
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). •
silure 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
[up to$250.00 a da a ainst the violator. Be advised to.t a copy of this statement may be forwarded to the Office of
tvestigations the DIA for insura r - overage veri a on.
do hereby certify un e ains a •penalties o p• jury that the information provided above is true and correct.
ianat&r • Date: 311 121017 '
hone#: Sorg:'35`{• 777g
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#: