HomeMy WebLinkAboutP-19-2818 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
E.Mrffi_:—_
n-le® � CITY Y1/MVln I-fn MA DATE ( g /I9 PERMIT#0-0/ illif asr(
=41=,� � J Gl
JO��BSSIaIT((EE,AD((D��RESS II5easfde VJla2e Y611110(141 MA OWNER'S NAME NI bet-i- "Oben
OW
P NERA4DRESS sr,Me, TEL t)C S69 Q1 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL Cl RESIDENTIALa
PRINT •
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:® PLANS SUBMITTED: YES 0 NOD
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 1 18 11 J 12 _ 13 14
BATHTUB !
CROSS CONNECTION DEVICE _ ._I /
DEDICATED SPECIAL WASTE SYSTEM ..
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 1.1011.,Mille Mil _
DEDICATED WATER RECYCLE SYSTEM _ -- -
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _ - i. _, _ _ __
KITCHEN SINK " -_- -- - - „ -
LAVATORY , I
ROOF DRAIN
SHOWER STALL _
SERVICE/MOP SINK
TOILET
URINAL _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I _ __ ,
WATER PIPING _
OTHER I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ID NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW '
UABIUTY INSURANCE POLICY Q 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.
ki- CHECK ONE ONLY: OWNER 0 AGENT 0
V
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are ue and accurate to the best of my knowledge
_1 and that all plumbing work and installations performed under the permit Issued for this application will be In pliance with all Pertinent provision of the
\� Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
c PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE
cr-
- MP❑ JP El CORPORATION❑# 3281C PARTNERSHIP❑# LLCO#
'S It COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 I
FAX 508-394.8256 CELL N/A EMAIL I accountspayable@efwinslow.com I
a. 0_ sit) ti;
•
\ 1I.I. ••••VIIflf&VI.IY..I.fil. y ars.sousin I.NJ4.iJ
1,e_.= Department of Industrial Accidents
r"_.')illi i - Office of Investigations
_E'f`_ . 600 Washington Street
Boston,MA 02111
' ` a.
i%` www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
� iName(Business/Organization/Individual): E fY.WlA5 i O . Y1�,,vp to ,
Celilt.l
Address: BI/Keoat,n
Cide.
City/State/Zip: Sough lmv,,c,jt'n NAr Phone#: 150E-399-711'1
iAre�!you an employer?Check the appropriate box: Type of project(required):
g r 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.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. 0 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 12.9 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
my applicant that checks box it 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 subcontractors and their workers'comp.policy information.
um an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation. //�� � I
surance Company Name: fI1f fp...s tkdl-tJcL ",tequat et to_ Cc,,tviy
)licy#or Self-ins.Lic.^^#: 15 a i /'e Expiration Date: 1-1 — aOl9
b Site Address:. 3 Carvw v cvi w-e0.141•1 MQ,, ae3A111.14 i 11 City/State/Zip: Oat4 k7
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 MOL 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..t a copy of this statement may be forwarded to the Office of
vestigations the DIA:for insurar - overage veri a'on.
to hereby certify un le ains a •penalties o p•jury that the information provided above is true and correct.
gnatu Date. la) 31 I ao]T
tone#: 51)%..114 t .777g
Official use only. Do not write in this area,to be completed by city or town official.
•
•
City or Town: • Permit/License#
Issuing Authority(circle one): O
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
5kk\
Contact Person: Phone#: