The URL can be used to link to this page

Home My WebLink AboutBLDP-19-002971 L\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING /,p F n- CIN YF/MO�4'H J MA DATE I I J9I pg I PERMIT# /&DP /7n—00a ` 7/ JQHSITE�ADDRESS IIIRoXrAcodCi frit YGfinOQM4OWNER'S NAME! Poi,92lien GajlVhtI I P OWNER ADDRESS ,5u 014 TELI50$114 1 a.45 IFAXI I TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL[ PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES NOD FIXTURES 7 FLOOR-* BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIIJSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN , INTERCEPTOR(INTERIOR) ,, KITCHEN SINK SW .1 ...fteginimm. LAVATORY ifs ii _ ,, ROOF DRAINwe - - - r, SHOWER STALL SERVICE I MOP SINK - _ i ,.- TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATER PIPING OTHER r - . INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITYINSURANCEPOLICYD OTHER TYPE OF INDEMNITY❑- BOND OWNERS 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 0 AGENT 0 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 :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 co r lance with all Pertinent provision of the sO Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / L Ar ...: .. - PLUMBER'S NAME I STEPHEN A.WINSLOW I LICENSE# 12298 SI " ATURE MPD JP . CORPORATIOND#I3281C IPARTNERSHIPD# LLC[O#I I v COMPANY NAMEI EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE I o .r- CITYI SOUTH YARMOUTH STATE MA ZIP 102664 TEL 508-394-7778 I FAX 508-394-8256 CELL N/A EMAIL I accountspayablenr,efwinslow.com 1 -,- f-4F • Gil* q' (I3 =O 11414 t us•MIIw.rrLMIII.V,{IINJJIIFIfMJLIW *,., Department of Industrial Accidents • ft-ft Office of Investigations jy 600 Washington Street Boston,MA 02111 'tkr`. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ,pplicant Information Please Print Legibly 'arae(Business/Organization/Individual): c.c•Wtys;ow Av .ji . trita. .rq Qe} I�1t. ddress: B' &eoc6n (')tt _. OY ity/State/Zip: Sou 'fcr,,,,c,,,tin t4Pr Phone 11: 503-399-171S7 e you an employer?Check the appropriate box: Type of project(required): ): cle-1 am a employer with '70 4. 0 I am a general contractor and I 6. 0 New construction 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 and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. [No workers'comp.insurance 5. 0 We are a corporation and its 9. ❑Build ng addition required.] officers have exercised their 10.0 Electrical repairs or additions ] I am a homeowner doing all work right of exemption per MGL 11.❑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 applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.eowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. actors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site motion. n anceCompanyName: AY193%,.) CiatifeA „Lnf tnC.P_ C kety yftorSelf-ins.Lic.#: visai A �^ Expiration Date: (—] — 1f>i9 / iteAddress:a3 .r ,ko-ecJ4ti, k1 C 344 NI City/State/Zip: COLI(o7 :h a copy of the workers' compensation policy declaration page(Showing the policy number and expiration date). t to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a p 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 to$250.00 a da a ainst the violator. Be advised t r.t a copy of this statement may be forwarded to the Office of :igations the DIA or insurapee�overage yeti a on. eCCreby certify un , I /penalties o p•jury that the information provided above is true and correct. ,► r. — 4_ Date: la 1 a01' r` #: �jg:314- "Mg1 ?elal use only. Do not write in this area,to be completed by city,or town official let • y or Town: • Permit/License# ting Authority(circle one): • loard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector )they ttaetPerson: • Phone#: c' • �, I