Loading...
HomeMy WebLinkAboutBLDP-19-001250 l 1, _Ai 6"or"is7 ) 7 7'O m7`lzcS,4M- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK s* , CITY YARMOUTH MA DATE 8/29/18 PERMIT# BLDP-19-001250 JOBSITE ADDRESS 116 WOODCREST LN OWNER'S NAME JEN SMITH P OWNER ADDRESS 16 WOODCREST LN WEST YARMOUTH, MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m • . PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES❑ NO m FIXTURES 1 FLOORS—. RSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES m NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY m 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 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 and 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME Stephen Winslow LICENSE#2298 SIGNATURE MP © JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Stephen A Winslow ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL efi • ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES e—: Yes No THIS APPLICATION SERVE AS THE 0 0 CCDIIT FEES S PERMIT* PLAN REVIEW NOTES " MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK iw=f Ctla CITY NIA/M0ti-lik rr MA DATE �ij (211I K PERMIT#3/ P'/y"dl /1 53 JOBSITE ADDRESS I C Wood r pe5+. k llthl7y'14J ft, OWNER'S NAME ;T01 5n4%AA i WW • P RADDRESS 5 7U9r41( Ri f�GIP Rd. Ac -toil I TEL 4117(, 0611 FAX TYPE OR OCCPANCYTYPE COMMERCIAL J EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:®- PLANS SUBMITTED: YES❑ NOW FIXTURES 1 FLOOR-. BSM 1 2 '3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM L _ DEDICATED GASIOILISAND SYSTEM r DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEMI DISHWASHER 1111.11 DRINKING FOUNTAIN II FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) a. KITCHEN SINK _ - LAVATORY ROOF DRAIN 11111111. SHOWER STALL URINAL MOP SINK • Nos E. TOILET r.�\! r- E L „ - WASHING MACHINE CONNECTION WATER HEATER ALL TYPES i 0 ? ./u tt WATER OTHER PIPING '. :pq Mt J awl I, 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 OTHER TYPE OF INDEMNITY 0 BOND❑ c> 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 EIAGENT ❑ SIGNATURE OF OWNER OR AGENT 0 I hereby certify that all of the details and Information I have submitted or entered regarding this application are true 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!' a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /! i -fr PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE �CC-- MPD JP❑ CORPORATION D# 3281C PARTNERSHIP❑# LLCD# s' cF COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE rte. 'S CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL NIA EMAIL accountspayableanefwinslow.com I . tilt • Ma ano ...wuu.w.arva.wwp J ariaaufseuaucaau k.,,,, Department of Industrial Accidents f • _."'nI=9t • Office of Investigations _ y 600 Washington Street : "�=i Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please(lPrint Legibly Name(Business/Organization/Individual): E•c•WIns iow �V,y�p1"3 g Oat-t , `e, Ii1C. Address: g Q eozi*t Ca(G�1?� a a City/State/Zip: So,sIsn `er•,,,,,o,,(4- (.{N Phone#: 'Y❑E-3 9-1774 Are you an employer?Check the appropriate box: Type of project(required): I 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 :.❑ I am a sole proprietor or partner listed on the attached sheet._ 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. ❑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 1.❑ 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#1 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 insurancefor my employees. Below is the policy and job site formation. I tsuranceCompanyName: �'yp,,.i rLvrt/a/i j- nom:.` C' yll Dlicy#or Self-ins.Lic.#: I$a I A- Expiration Date: c—I aolq )b Site Address: 3 Gvv,rv,o,n1/4N-ea-II-II .k4I C3'1&4. IbiI City/State/Zip: 0a4 to7 ttach a copy of the workers'compensation policy declaration page(Mowing the policy number and expiration date). inure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ae 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..t a copy of this statement may be forwarded to the Office of .vestigations the DIA or insura overage vert a on. to hereby certify un e p•jury that the information provided above is true and correct. 1 gnatuT • _ 1 Date: l ai 311 aoll lone#: Stj'd;35`1 r 797g Official use only. Do not write in this area,to be completed by city,or town official. • \ City or Town: • Permit/Licehse# :-....\< �v 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#: p 1\