HomeMy WebLinkAboutBLDP-17-3908 r �..-1
MASSACHUSETTS UNIFORIW APPLICATION FORA PERMIT TO PERFORM PLUMBING WORk
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s`_'"=y CITY tM A/ ..# (10 4,MA DATE�`7-"_&/u 1PERMIT#I14D1' of
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JOBSITEADDRESS ZJ//-T( -1OWNERS NAMELLt& /Lr1r6t
OWNER ADDRESS .... SI __i W �'I TEL� Wel FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL® 1,0 El C ONALUM RESIJEIt Aleti lie-id �NTIIAL�
PRINT ••
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES { NOW
FIXTURES 7 FLOOR-4 BSM •1 2 3 4 b 8 7 8 9 10 11 12 13 14
BATHTUB ANSI- ASII ._ '; - 1'_ .I- . AM J. --t�1dl11
CROSS CONNECTIONDEVICE . / iik� _. �aft
DEDICATED SPECIAL WASTE SYSTEM WMMSMSIMOMMI1
DEDICATED GAS!011/SAND SYSTEM SiraripternignMINVISMAISMINSWIM
DEDICATED GREASE SYSTEMIMMISi, , iaijleilffa
DEDICATEDGRAY WATER SYSTEM m® ismamicummuss
DEDICATED WATER RECYCLE SYSTEM arnitgannINSa 'Ma
DISHWASHER • I[M � lea [.
DRINKING FOUNTAIN atialignitilS. IlliMMINEMS
FOOD DISPOSER • ISIONMallatelinnida
FLOORIAREA DRAIN MilINIOSSMISSMIElantilleal
m INTERCEPTOR INTERIOR SCf M IS
V KITCHEN SINK MISMjiS lMj) a'-� `, ta 'M
LAVATORY MMISISINNOMM ra
ROOF DRAINariatlaWal lM intael
SHOWER STALL in � - -.I ____ 1:: OM::
SERVICE I MOP SINK " t ( INIMj
TOILET l M �l _ ,. !�
V, URINAL MilaarrilSOMUIRISIONISSISISIMMI
WASHING MACHINE CONNECTION St, ,nEnjrnins I
WATER HEA IERALLURES SartitarigreSSIOWnMentrinn
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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. YEd 9 NO Q
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKINGTHE APPROPRIATE BOX BELOW •
•
LIABILITY INSURANCEPOUCYI OTHER TYPE OF INDEMNITY Q BOND Q-
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 waivesthis requirement, •
• CHECK ONE ONLY:• OWNER U AGENT l
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:nd accurate to the best of my knowledge
and that all plumbing work end Installations performed under the permit Issued for thla application will be In compl'ce with all Pertinent•rovislon of the
Massachusetts State Plumbing Coda and Chapter142 of the General Laws.
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WINSLCW .i�� R i,��a.�
PLUMBER'S NAME STEPHEN A.
,LICENSE# 12298 i SIGNA RE
MP DI JP® CORPORATION +�# 3281C `PARTNERSHIP# .LLC®#=le •
COMPANY NAME EF WINSLOW PLUMBING&HEATING II ADDRESS B REARDON CIRCLE 1
CITY SOUTH YARMOUTH STATE MA ZIP._02664 • TEL 508-394-7778 „sal I '
FAX 508394-8256 CELL NIA • EMAIL amounts a l efwinslow,com �1 LI (T
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.:,4=1y, a//j66 c Hy Yr6YB:D'66g"666 um'
t. =bit=° .. 600 Washington Street
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JO Boston,MI 02111
,,, ,,T.: www.anass.gov/dia
Workers' Compensation Insurance Affidavit:Emilders/Contractors/JElectriciansIPltllbers • '
e mplacardInffornmafion r^ t /� Please Print Legibly
same(BusinesslOrganizaflon/lndivlduel): G•4",Et�id 'S1th l yliv,natsu e 0-ea �, e'.,ininto
Address: IT etdn • Ci 0
2ity/State(Zip: jos;In Ycnr-ity...kin Or Phone 1: 53S•3c'1r'MS?
re you an employer?Check the appropriate box: Type of project(required): •
�I am =player with 70 4. 0 I am a general contractor and 6. 0 New construction
employees(full and/or part-time).* have hired the sub-contractors
o I am a sole proprietor or partner- listed on the attached sheet.t 7.•0Remodeling
slip 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
lO.OBlectricalrepahsoraddflons
0 I am ahomeowner 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.]
ny applleantthat checks box#I must also fill out the sectionbelow showing theirworkers'compensation policy information '
lomeowners who submitthis affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such
'abettors that checkthis boxmust attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information
un an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation. {� { � (1 I
suranceCompanyName: Arrah,.i t"(n)d-tai( ,l�n1INLIeleL l nlivavV 1
dicy#orSel€ins.Lio.#: \' i A •
,` Expiration Date: (—i— )•on
bsiteAddress:23 1nmti nu t0-1Th AJ, )M
Ceg ' k��l City/State/Zip: 0,:-)4t 7
flack a copy of the workers'compensation policy declaration page(thawing the policy number and expiration date).
Ewe to secure coverage as required under Section25A of MOL c.152 can lead to the imposition.of criminal penalties of a
le up to$1,500.00 and/or one-yearimprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline ,�`
'up to$250.00ada a:ainstthe violator, Be advised$t a copy of this statementnay be forwardedto the Office of
vestigationsr the DIA for instrayee,Overageye pteIon • t
to hereby eerily))un e •a e (SINS
II penalties o p jury that the Information provided above is true and correct. •
gnatu o 42 Date: (al 31'Role'
ione#: 9$.' 91-'197$ . \
Official use only. Dont write in this area,to be completed by ayor town official . V l^"
City or Town: Permit/Lieense# 0 1
Issuing Authority(circle one):
1.Board of Health 2.BnrldingDepartment 3.City/Town Clerk 4.Electrical Inspector 5.PlumbingInnspector
6.Other
Contact Person: . • Phone it: .