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HomeMy WebLinkAboutBLDP-19-002377 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ''-,11,/ CITY 'ammo ll4 J MA DATE HO/1611 Q) J PERMIT# jA7'9-a0 if JOBSITEADDRESS LQ1 Pityl.J S}, 500kYkotoulth OWNER'S NAME Dan Eii%134 tCk P OWER ADDRESS 6g 1I4Afig-Q(r U4lcbnktMA. 01040 1 TEL 983914 a ' ' JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT ' CLEARLY NEW:❑ RENOVATION:EJ REPLACEMENT: PLANS SUBMITTED: YES 0 NOD FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _ DEDICATED SPECIAL WASTE SYSTEM SMK- _ ®fit^`- �, __�_ I DEDICATED GASIOILISAND SYSTEM _a � DEDICATED GREASE SYSTEM �� ���� DEDICATED DEDICATEDWATERRAY ATER RECYCLE TEMSYSTEM DDISHWASHER RINKINGF UANARNECYCLESYSTEM11111::::__ �'r_r_�Ie-_S`I.I. FOOD DISPOSER D ��� i�l� l� �l �. FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) Mi,'M ISMSL KITCHEN SINK Mina _�r, LAVATORY r ROOF DRAIN s_�s■ i SHOWER STALL 1110.1.1111011.1....MM r _r_ , li SERVICE I MOP SINK 1 TOILET 111,111111111 URINAL _.`_`11111. WASHING MACHINE CONNECTION Mil„MN.M.,ME, I �,II III IIII WATER HEATER ALL TYPES RBI WATER 111111111111111111111111, — r r OTHWATER PIPING _ I r _- ,�a=r .� a INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requir ments of MGL Ch.142. YES D NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D 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. CHECKONEONLY: OWNER 0 AGENT 0 L, 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 ,t: andaccurate to the best of my knowledge ,/1 and that all plumbing work and Installations performed under the permit issued for this application will be Inco prance with all Pertinent provision of the O Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER'S NAME I STEPHEN A.WINSLOW LICENSE# 12298 f SI- ATUR rv+ MP❑+ JP CORPORATIOND# 3281C PARTNERSHIP EP LLC©#I 1 fa •� COMPANY NAME EF WINSLOW PLUMBING 8 HEATING j ADDRESS 8 REARDON CIRCLE Sz S CITY SOUTH YARMOUTH 'STATE MA ZIP 02664 TEL 508.394-7778 I AS FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com J Alli- 0 6 • MCI a 1 I/4 •.'V/IMISIMMt1• I•V /IaMJJMVIIMJLLW 1*e== Department of Industrial Accidents (t Office of Investigations is _l i 600 Washington Street, -- Boston,MA 02111 . : .,;, ` ' ,' . www.mass.gov/dia• I Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C 1 Please Print Legibly Name(Business/Organization/Individual): E.c.WIv.,SI0,W Y(u ,,6; tc{ a Oto�}-1 , Qe.) jn(, Address: ce Kpo tin �';�Q. U !Jl City/State/Zip: Sou Ain `fcrN,0,,("l•, NA' Phone#: 'V3- 399-7'1?9 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 6. ❑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._ 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'camp. 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 box#I 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. un an employer that is providing workers'compensation insurance for my employees. Below is the philcy and job site formation. //�� 1 surance Company Name: f1fl .,.3 (`1u k- a d_rt f n c cO ,ytAily I llicy#or Self-ins.Lie.#: Visai A- Expiration Date: (—F- aOI9 b SiteAddress:23 Cetrvyncinn..teo-, 4, M'Q/ Clfe3 Ibti City/State/Zip: O?'-1(07 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 l le 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 ti.t a copy of this statement may be forwarded to the Office of vestigations the DIA or incur.i " overage vert a on. to hereby certify un • to ains a I penalties o p• jury that the information provided above is true and correct. gnaSr.' Date: (al ?' ) a0{7. ) tone#: SOL 314. 7?7X . Official use only. Do not write in this area,to be completed by city or town officiaL • i • City or Town: Permit/License# \ Issuing Authority(circle one): 0 I 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: