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HomeMy WebLinkAboutBLDP-19-002071 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK •17f' ,E=y=Er f ''PERMIT# '_/ �_r �• °'� CITY ' "r�`� ` " ` IMA DATE Noo _. JOBSITE ADDRESS I7K Cr4.t2t Rarc�aSP Rd WYE OWNER'S NAME I_ _ [ p OWNER ADDRESS j2P ;djrvPS ' t , OPS-1-MJ I TEL $_ 130/b 'FAX -- J , Ol0 S TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL U RESIDENTIAL PRINTPLANS SUBMITTED: YES® NO �+ CLEARLY NEW:® RENOVATION;U REPLACEMENT: to 10113101101 S2 FLOOR-4 ®Q©©©0_ 6 Minn CROSS CONNECTION DEVICE SMSMTSSSOSSIM �r DEDICATED SPECIAL WASTE SYSTEM a' ` s ,,..,,r�1� ' DEDICATED GASIOILISAND SYSTEMISe DEDICATED GREASE SYSTEM Si10 CATED Y WATER SYSTEM ` DISDEDIHWASHER�ERRECYCLESYSTEMIr S [ O1tilSti 1-.7 TAIN WIWRIMIS ONittalS .moi IWI - r _ 0 0 SM ittlaSOMWOMPI r— r - LAVATORY �r��� � r ,� �� � ROOF DRAIN S'. e __ SHOWER STALL Sl i'LSS!SSI SERVICE IMOP SINK 0 ' Iti M0 � I tfl CONNOril efellial WASHING MACHINE CONNECTIONTIMIWWIRWINPUITIO sij!JEJlIIIIifte s "5- atituntastastiosassesist OTHER ..�� INSURANCE COVERAGE. (' Ihave acurrent liahili insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142. YES W+ No® to IF YOU CHECKED YES,PLEASE INDICATETHETYPEOFCOVERAGE BYCHECKING THE APPROPRIATE BOXBELOW 4c war(INSURANCE POLICY 0 OTHERTYPE OF INDEMNITY eO 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. AGENT CHECKONEONLY: OWNER • SIGNATURE OF OWNER OR AGENT and that all pluthat all of the mbingW work end installai ns performed under thesubmitted permit Issued orregarding applicathis tion will be In cc,cation are 'lance with ell Pertinent provision of ths.and accurate to the best of my e Massachusetts State Plumbing Code end Chapter 142 of the General Laws. _„ . ... PLUMBERS NAME STEPHENA.WINSLOW LICENSE# 12298 SIGNATURE- �uC®#E • MP DI JP® CORPORATIONS+ # 32810 'PARTNERSHIP®# COMPANY NAME EFWINSLOW PLUMBING&HEATING IADDRESS B REARDON CIRCLE STATE MA ZIP 508304 WB CITY SOUTH YARMOUTH . 02664 TEL- - accounts able _ -- FAX 508508-394-8256508-394-8256 CELL MI=EMAIL __ • The ;Rigor.-Vit, Commonwealth° Massachusetts i,nf- Department°flndustrialAccidents ee1af e '1 Congress Street,Suite 100 .jt� Boston,MA 02119-2017 I Workers' www..massgov/dia Compensation Insurance Affidavit:General ttusinesses. A,a licant Information TO BE PEED WITH TEM pg,RryTINGA • maolmrrr Business/Organization Name:E.P yNNSLOW PLUMBING&HEATING CO.,INC pease Print a II' Address;8 REARDON CIRCLE City/state/zip;SOUTH YARMOUTH,MA p2664. Are you an employer?Check thea phone#:508p94 regi I.0✓ Iamaemployer with"((1 pprmploees( y^� BusUmR e(regnred): 2,® or perm-time).+ employees(fulland/ Iamasole proprietor orpartnershipandhaveno em to eesWorkn 6. ORestaurant/Bar/EatingEstablishment • P Y gformeinanyca [No workers'comp.iasmance require rty7. 0Office and/or Sales(Incl real estate,auto,etc.) • 3.0 We are a corporation and its officers have exercised 0 Non-profit oerightofexemption per c.152,§I(4) and wehave • 9. ❑manu Entertainment q•�] We are ayemployees.[No orkers'comp.insurance required? ion manufacturing ng with e employees.rofi organization,staffed by volunteers, 11.[f Health Care *Any applwith nohat checks [No workers'comp.' *Anna co box#1 must also fill outthesrasnraacewingt 12.0 other organization shatedc have exempted themselves,butha no6elowahovnngtheUwodcem'COmPausationpolicyinfoanetioa **tithe corporate orateocheak box#I. corporation has other employees,a workers'compeusatioapoltcy Is required end such an I am an employer that Zsp ropidingworkers'compensation fnsurancefor my employees. Below tslepolicytnformatorARROWMUTUAL INSURANCE COMPANYInsurnee y Insurer's Address.23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL,MA 02467 Policy#or Self-ins.Lio.#1821A Attach a copyoftheworkets'compensation policydeclarationpage(showing�epolic numbe/�1t Failuptosecurecoangorsre edunder Section 25AofMGLc.152can leadtothe ynumbefandlpnal expiration foeup o$1,50.00 a one-year imposition ORDER fa Investup igations copy1forinsrancetor.PeadvisedthatarmofaSTOPNIS LA for insurance coverage er' ofthis state ed to the ORDER and a fine 8 v £cation meet may be forwarded to Office of Idoherebyeerti � ' naliteso perjuryll,attheinformattonprovidedaboverstrue andeorreet. Sly afore: � + ' L .=sry i,,,, ,. Date. • 3/ l hone;:508-394-7778 OffktaZuse only Da not write in this area,area to be completed by city ortown official • Qty or Town: \ 1 IssuingAuthori Permit/I,icense# ty(ctrcle one); 4\ 6.Other f$ealth 2.Ztaild�gbe 6.Other Partmeaf 3.City/fawn Clerk 4•Licensing Board 5.Sete A� Selectmen's Office 01 Contact Person: Phone#: �A masa.gav/die `N. ,