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Home My WebLink AboutBLDP-19-001483 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK F= ' w,=li �� N� /' l n r� AI"? CITY 9H'.K-7�r I h LSn41 N) I MA DATE 9/,�/S I PERMIT# e''i) —R °°/L/f✓ JOBSITE ADDRESS 1 JMrgrnew0 nue I OWNER'S NAME ,JOSE/H J--gdiitt P OWNER ADDRESS .5/int TEISOK 71432. 1 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL ❑ RESIDENTIAL El PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD FIXTURES 7 FLOOR-. 8SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM I - — DEDICATED GAS/OIL/SAND SYSTEM ( 1 J _ _ _ DEDICATED GREASE SYSTEM T DEDICATED GRAY WATER SYSTEM l 1. ll DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKINGFOUNTAIN lull_I I r F FLOOR/AREA DRAIN Op INTERCEPTOR(INTERIOR) r �� MI ? KITCHEN SINK LAVATORY _ ROOF DRAIN 10 SHOWER STALL 7 '" SERVICE/MOP SINK TOILET r URINAL WASHING MACHINE CONNECTION I n 1 WATER HEATER ALL TYPES WATER PIPING LI �r OTHER r - r i 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY ❑ BOND❑ , 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. SCHECK ONE ONLY: OWNER ElAGENT 0 Ps - 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.:f,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 comp,' e 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 CORPORATION El# 3281C 1PARTNERSHIP❑# LLC Lk CA COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com aIf 66 if acia a.... wor•a.uu.0 vJ 41u.Jul...nu4..W Department of Industrial Accidents 1 _ Q1 gt Office of Investigations • • =1i''le Z 600 Washington Street - Boston,M4 02111 %if:1� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please( Print Legibly Name(Business/Organization/Individual): E•C•Wi z fr s. 10>N QkU,•,lo tel t t1<o.1 ' 6 `e.} frit. Address: Kporlt�t �';rd+Z_ Q d City/State/Zip: ScAin /CYtr^o-Ain N{k Phone#: `503. 39`1-1'17x! Are 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 6. 9 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. 9 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions t.❑ 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 12.9 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp. insurance required.] thy applicant that checks box NI 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 subcontractors 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. /� LIC.. ( tsurance Company Name: I ym..-1 CA i t•tJI3 A f(r2linto_ \1 gnitvty olicy#or Self-ins.Lic.#: 1 S al pr • '1 Expiration Date: t—I — a019 )b Site Address:. 3 r"re✓1wee-11"h i C623kAiii• rn • ‘1 City/State/Zip: CaA-1107CT)„. 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 F 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 tvestigations the DIA for insura overage verif a on. do hereby certify un e ains an penalties o p jury that the information provided above is true and correct. *. ianatuT : Date: (d' 31 I apt. - hone#: Sl')g:35i. -Mg c‘\ Official use only. Do not write in this area,to be completed by city.or town official • ` City or Town: Permit/License# L..,.---,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#: t