HomeMy WebLinkAboutBLDP-19-002373 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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` .fl r CITYI Ynre,ry}1, I MA DATE In I IS /! $ PERMIT# ®.i--.D/-/9-5Va n
JO ST ADDRESS 12.t4 QIeasan4 S4 . S,Y,,c,no t OWNER'S NAME NR(lei A
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OWNER ADDRESS Srtw4P TEL 508 39q $61 I FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NOD
FIXTURES 1 FLOOR-. esM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _
CROSS CONNECTION DEVICE RP
DEDICATED SPECIAL WASTE SYSTEM
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DEDICATED GAS/01USAND SYSTEM
DEDICATED GREASE SYSTEM 1
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DEDICATED GRAY WATER SYSTEM I
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER • I
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR I AREA DRAIN _ F
INTERCEPTOR(INTERIOR) l a
KITCHEN SINK - •
LAVATORY1
ROOF DRAIN _ 1
SHOWER STALL
SERVICE 1 MOP SINK ( ,
TOILET
-
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES __ _ _
WATER PIPING
OTHER r j
_ I
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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. YES Q NO ❑
0 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 0
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h OWNER'S INSURANCE WAIVER:lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the
8 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
^'t!"- CHECK ONE ONLY: OWNER 0 AGENT 0
re,�p SIGNATURE OF OWNER OR AGENT—
iv M I hereby certify that all of the details and Information I have submitted or entered regarding this application are truand accurate to the best of my knowledge - -
• 'p and that all plumbing work and installations performed under the permit Issued for this application will be In corn h nce with all Pertinent provision of the
CP tpMassachusetts State Plumbing Code and Chapter 142 of the General Laws. / �
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etV PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE
MPD PEI CORPORATION # 3281C PARTNERSHIPO# LLC❑#I
COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH J STATE MA ZIP 02664 TEL 508-394-7778 I
FAX 508-394-8256 CELL NIA EMAIL accountspayable(a,efwinslow.com I
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Department of Industrial Accidents ' .
It------".=.alilt €'t Office of Investigations
G lai= 600 Washington Street.
' &•;::= Boston,MA 02111
� :044 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): E C.W IVS$I O W Oths- o kny 1 11 vita �,
ln� Q Cel l•'tC.
Address: 3Keocksn C:irci ..
City/State/Zip: So,1 ieN `Wt-,c,,sr n Ptpr Phone#: ¶)8-399-1'1?.!
Are you an employer?Check the appropriate box: Type of project(required):
Xam 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.I 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 area 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 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp. insurance required.]
1 n applicant that checks box N I 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 sub-contractors and their workers'comp.policy information.
zm an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site (i
suforance C. Arm.)
surance Company Name: n1f{'pt,.l (`l.l�e•A (r,f�n� C�t,^y j
Ilicy#or Self-ins.Lic.^^#: 1$a I Pc 1, Expiration Date: ‘—I — a09la
b Site Address:aG3 v cvl w-e0 - A-4 21 CG,eg • 14II City/State/Zip: Oar[lc)7
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 MGL c. 152 can lead to the imposition of criminal penalties of a 1V,\
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 a fine
up to$250.00 a da a:ainst the violator. Be advised t rat a copy of this statement may be forwarded to the Office of
vestigations • the DIA or insura• - overage yeti a•on.
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fo hereby certify un te ains a .penalties o p•jury that the information provided above is true and correct. N
gnatu •
Date: (a) 31 1 21017-
tone#: co,:3 - 777K •
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Official use only. Do not write in this area,to be completed by city.or town official f
•
City or Town: • Permit/License#
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#: