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HomeMy WebLinkAboutBLDP-19-002215 (..J., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CV; CITY YalMtl0—h I MA DATEI 10/451)4 11PERMIT#/ OtR 00tr • tr JJO�BBSSIJ,EADDRESS SQ Jo jCeStferi•lo1DJ-}h OWNER'SNAMEI MAy !? Wel(k 66R(6ADLd P OWNERESS 5 e i TEL SO8344Va-4—q/1FAX ` TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL © RESIDENTIAL ' PRINT CLEARLY NEW:© RENOVATION:0 REPLACEMENT:2r PLANS SUBMITTED: YES 0 NO0 CROSS CONNECTION DEVICE ( 1 2 3 4 5 6 7 8 9 10 it 12 13 14 BATHTUB FIXTURES 7 FLOORS eSM- f - YU _ - � DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GASIOWSAND SYSTEM DEDICATED GREASE SYSTEM __ __ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM -._. alillle DISHWASHER FLODOISPOSE RAIN � �r FDOODISPOSER FOUNTAINRINKING It -_�--- INTERCEPTOR(INTERIOR) _ __ KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE TOILET URINAL IILET 1 MOP SINK L i , b i _ -, WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING - - - - OTHER L INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 0 I' LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY 0 BOND 0 1n ' OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the —1-- Massachusetts General Laws,and that my signature on this permit application waives this requirement. N CHECK ONE ONLY: OWNER 0 AGENT ❑ u 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 Ln and that all plumbing work and Installations performed under the permit Issued for this application will be In co .lance with all Pertine,t provision of the Z. Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -Are - O PLUMBER'S NAME I STEPHEN A.WINSLOW (LICENSE# 12298 SIGNATURE `�� MPQ+ JP CORPORATIONQ# 3281C PARTNERSHIPQ# LLCQ# I L S COMPANY NAME EF WINSLOW PLUMBING&HEATING J ADDRESS 18 REARDON CIRCLE J CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 1 FAX 508-394-8256 CELL WA EMAIL accountspayable@aefwinslow.com i '(' a SILL L.vn*ILavfrrtIL*u*ICI OINpJILLI*NJL**u I ems,= / DepartmentoflndustrialAccidents 1—r� Fier-- Office of Investigations _ilii_F. �i 600 Washington Street Boston,MA 02111 tO i..=_49' . V-ZrViir www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): E.F.w 10,,,, OtO.ti.bi✓vct g �I<0.1;1 Ce, In(.* Address: 3 &eocltsn C)dQ. City/State/Zip: Sou k YcrwrsA-tn t&Pr Phone#: 'US-399-177C1 XAre you an employer?Check the appropriate box: Type of project(required): I am a employer with 10 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• ❑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 required.] officers have exercised their 10.0 Electrical repairs or additions .❑ 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 my applicant that checks box HI must also fill out the section below showing their workers'compensation policy information. • iomeowners 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. sm an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site formation. 1 surance Company Name: A(ypv,.� rlL!-tlo l '-�in fuct n to_ Ca vt1 Ilicy#or Self-ins.Lie.#: l isa I A • Expiration Date: (—) - aol9 b Site Address:a3 Connrnctel kg-ea-4h AM1 av(j..4 I-‘111 City/State/Zip: tzar-I1,e7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a to 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 t•at a copy of this statement may be forwarded to the Office of vestigations • the DIA or insurar - overage veil a'on. fo hereby certify un e aim a penalties o p•jury that the information provided above is true and correct. - ' gnatu • Date: (al?! I ao17t ! tone#: S)g,' 9. 777X `� \ j Official use only. Do not write in this area,to be completed by clotor town official • 1 • 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 ivvvk\ 6.Other Contact Person: • Phone#: \