HomeMy WebLinkAboutBLDP-17-004958 MASSACHUSETTS UNIFORM APPLICATION FOR A FERRET TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS I ite �•(r.•rk {fir{;OWNER'S NAME D ick -7 rPe f i
p OWNER ADDRESS ISA() PrtPrC,cn I id TSn h i-01mA rd �O4SISFAX 1
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TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL Q. RESIDENTIAL I
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CLEARLY NEW:0 RENOVATION:® REPLACEMENT:0...-- PLANS SUBMITTED:YES0' NOu+
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FIXTURES FLOOR-) BSM •i 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB r- 1 Q ___ . ''---_ L. ..JC`J-:; - �_tl.. ._..-_. S tl . 1.
CROSS CONNECTION DEVICE R _ - _ .I,. -_ I _._ir!, (' +.moi _ I . I
DEDICATED SPECIAL WASTE SYSTEM frt—us 1, ,+- . I J 4 „ _1
DEDICATED GASIOIIJSANDSYSTEM — '
DEDICATED GREASE SYSTEM ._., . II. . . ; . -.1SI ) . L__..E_I _.1- ----'_-- -1--7
DEDICATED'GRAYWATERSYSTEM I.. (I IG. (moi -. (--L LJ �(-I.•.0--3r
DEDICATED WATERRECYCLE SYSTEM 11_1,_ JE j fl, \..i1 t .iL . 1_p�L� ,^I 7
(SO ._ 1= C.- . I[—, t .. fv._s
T.-DISHWASHER •
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FOOD DISPOSERAIN in-ir_-_ ...__. ..-71-r
__ :r., i L....__ ,...,1:-- rill_ mi.._ I_
Y l FLOORIAREADRAIN C-5-... I __ .rv-,. C -- c :..C,: _1, :..-` .
v INTERCEPTOR INTERIOR ., '[ (- _ 'lM _ I
KITCHEN SINK .771I7-1,� .: St CT' .. --- •
LAVATORY
ROOF DRAIN 73 77.)1/4=177,1„.„_ .1 ,..
SHOWER STALL
o _SERVICEIMOPSINK I_▪ ESS; �I ( _w'—:
TOILET • � i
URINAL ICI _
WASHING MACHINE CONNECTION L 11-----7-is _ 1 -.. 1— �
WATERHEATERALLTYPESd ... _..
• WATER PIPING S � ,I ,
OTHER _ "- . Sett :_ . . , . ..
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INSURANCE COVERAGE:
' I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES0+ NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKINGTHE APPROPRIATE BOX BELOW •
LIABILITY INSURANCEPOUCYI OTHER TYPE OF INDEMNITY 0 BOND 0•••
(1Y) OWNER'S INSURANCE WAIVER:I am aware that the licensee does not havethe insurance coverage required by Chapter142 of the
M Massachusetts General Laws,and that my signature on this permit application waives this requirement,
— CHECK ONE ONLY:• OWNER LI AGENT ® -
+ SIGNATURE OF OWNER OR AGENT
N thereby certifythat all of the details and information I have aubmfted or entered regarding this appllcatlon are true and accurate to the best of my knowledge
end that all plumbing work end Installations performed undertha permit Issued for this application will be In cm/Ince with ell Pertinent provision of the
Massachusetts Slate Plumbing Godsend Chapter 142 of the General taws. -
0— PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 ' / "
SIG i•'LURE
MPI JP® CORPORATION +j#I3281C IIPARTNERSHIPO# .LLC®#1 '
COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDCN CIRCLE 1
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CITYISOUTH YARMOUTH ISTATE 1, MA jZIP 02664 . TEL1 08-394.7778 I ��
FAX 5083948256 CELL NIA EMAIL accounts a able@efwinslow•co 1
.g�y-i i�—C Ifjp1.c lu drsvgsugaaauf Y
—s;� 600 Washington Street
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�` t_ ` ioston,Mail 02111
r,_ www.masagov/dia •
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricnans/PlnmberS •
tpplicantInfornnation •• /i Please Print Legibly
game(Business/Organization/Indivldual): t–"C'.WtdS1OW '4'tU:M�iekci L Of0-( `n-,Int.
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Mddress: I" KP niacin . ctrrtt. _ • .
^ty/State/Zip: 5OU k'n yo+rl'- ittn t`-Or Phone#: tO .3(1ir Ile/St '
:re you an employer?Check the appropriate box:' Type of project(required): •
I am a employer with `70 4. ❑I am a general contractor and I 6. ❑New constnrctko.
employees(full and/or part-time).* have hired the sub-contractors
❑I am a sole proprietor or partner- listed on the attached sheet= 7.•0 Remodeling
ship end have no employees `' These sub-contractors have - . 8, 0 Demolition -
working`forme in any capacity. workers'comp.insurance. 9. ❑Building addition '
[No workers'comp.insurance 5. 0 We area corporation and its
required] officers have exercised their 10.E Blectricalrepa rs or additions
❑I am a homeowner doing all work .right of exemption per MGL 11.E Plumbing repairs or additions
myself.[No workers'comp. • c.152,§1(4),and we have no 12.9 Roof repairs
insurance required.]V' employees.[No workers' 13.[]Other
comp.insurance required.]
ny applicant that checks boc#1 must also fill outthe sectionbelow showing their workers'compensation policy information, '
lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
ontractors that check this box must attached an additional sheet showingthe name oldie tub-contractors and their workers'camp.policy infbrmatin
int an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation. {� . •
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anance Company Name: f'IYypv� rik kit 3 npu et(..Q., 0 owNefv `i
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ilicy#or Self-ins.Lie.#: VI Ds.I A ,I Expiration Date: f—V D,D '9 t
b SiteAddress:a3 rAcn.al2Jhn ,,ice, Ct sr�' I City/State/Zip: 6)4( _) •
Rach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
dhae to secure coverage as required under Section 25A of MOL c.152 can lead to the imposition of criminal penalties of a
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 afine
'up to$250.00 a da a ainst the violator. Be advised t at a copy of this statementmay be forwarded to the Office of .
vestigations the DIA for insurapea1overagever7 a on. • /
io hereby certify un e p
ns JJ snaffles o pjury that the information provided above is true and correct. •
gnatut , A. Date: I ai 31 R01(
. lone if: 501•3Ti•'?978 •
Official use only. Do not write in this area,to be completed by di)?or town official .
City or Town: Permit/License# •
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electricallnspector 5.PlnmbingInspector
6.Other
Contact Person: . • Phone ft: