HomeMy WebLinkAboutBLDP-19-001623 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
lo CITY aYM c IMINIMIIIIIa MA DATE' /Pi I I t I PERMIT#/"WP-R-Ct9i ba3
- JOBSITE ADDRESS 1315Un;cn St. 5'.Velem 44 I OWNER'SNAMEI Me ((r-F6•d 1
P OWNER ADDRESS 13.15 j.jeittaN SF. S Ya✓ntaki1 HN O TEL 5o8-347{- iloc IP- FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL®K
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:2' PLANS SUBMITTED: YES 0 NO❑+
FIXTURES 7 FLOOR-+ � BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BCARTOHSTSUCBONNECTI• . lala 1MM.].min Es
DEDICATED SPECIAL WASTE SYSTEM mil in a gm riefti miiii.II.an 111.Mill _ _ NMI MI
Men _ la Nat NMI PIM 1•1111111111,101.1 IIIIIII NMI INN
• E
ISMIMI
DEDICATEDJLi%t_jjfl®1
( DRINKING FOUNTAIN nligralin1111
��� �
Ma
Q FOOD DISPOSER MN
FLOOR I AREA DRAIN Mai_. ....— •
`69 INTERCEPTOR INTERIOR MN��r SIM
KITCHEN SINK a anilltia.'laa
LAVATORY l=M
• ROOF DRAIN MINNSIM� 11 --ll
SHOWER STALL ='
SERVICE'MOP SINK ��� �
T TOILET
URINAL- ME a-
T WASHING MACHINE CONNECTION —_I M'n,n MB
be WATER HEATER ALL TYPES =MR=_eta �■
�� WATER PIPING
OTHER - flfl
Q — - .
- INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO ❑
00 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q 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 ❑ 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 t . d 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 ce with all Pertinent provision of the
_ Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER'S NAME STEPHEN A.WINSLOW 'LICENSE# 12298 SIGNATURE
MPD JP CORPORATIONQ# 3281C PARTNERSHIP❑# LLCa
COMPANY NAME EF WINSLOW PLUMBING&HEATING J ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 502-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com
4/
ft 0 Nay
•
(CYC /..) --1;
MIA a 111 •-•VIIIIIwn,yc_,•••I•Qv ora Iluuul.I/w.II.Iw
—w—Ri Department of Industrial Accidents .
5= Ml_ Office of Investigations
•600 Washington Street
Yv ! Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information f / /� Please Print Legibly
Name(Business/Organization/Individual): E•l-•Wins'ow YtU.A.%6 2, titClrevi Qs., SCI
Address: B' Coda. Ci ie-
City/State/Zip: Sas `fcrt-c,,, to 1-tor Phone#: '508-394-117V
XAre you an employer?Check the appropriate box: Type of project(required):
am a employer with '70 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
:.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. 0 Building addition *----$.
[No workers'comp.insurance 5. 0 We are a corporation and its
required.] I officers have exercised their 10.❑Electrical repairs or additions
I❑ 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'
comp.insurance required.] 13.0 Other.
1ny applicant that checks box HI 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. //�� � mf
isurance Company Name: &y ,J rk,i t-ti0A (`ft n tJ2_ Ca#ivy
olicy#or Self-ins.Lich.^#: 'Sal Expiration Date: (—I — a019 Q) �+
ib Site Address: 3 �rvwttvlw2aJ(11 Asst CFe34 .j1• Nal( City/State/Zip: Oar-1117 I�
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 rme
'up to$250.00 a da a•ainst the violator. Be advised t t a copy of this statement may be forwarded to the Office of
.vestigations • the DIA:or insura overage vert a on.
•
lo hereby certify un e airs a penalties of p jury that the information provided above is true and correct.
I
gnatuIL. Date: lai am"
i
lone#: SUq:31`(- 7978
Official use only. .Do not write in this area,to be completed by city or town official -
•
City or Town: . Permit/Licehse# I
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other I
Contact Person: I i
• Phone#:
le
1
I