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HomeMy WebLinkAboutBLDP-19-3073 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING e=-e— �� CITY YdIMgJ��, � MA DATE I l 110 �I� ����I PERMIT#� d 79 ,i =t� JOBSITEADDRESS JO Sigh) Ln IAI0Pfrngj4l+ 0103 OWNER'SNAMEI AdaIfro (e.4 hI I P OWNER ADDRESS got/1141 ITEL 50911`d0010 FAXI I TYPE OR OCCUPANCY TYPE COMMERCIALD EDUCAT 0 RESIDENTIALE PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: jraoc.O., PLANS SUBMITTED: YES NOD FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 _. . BATHTUB _ _ _ CROSS CONNECTION DEVICE ._ DEDICATED SPECIAL WASTE SYSTEM _. DEDICATED GASIOILISAND SYSTEM ' DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM - ._ DISHWASHER ___ DRINKING FOUNTAIN - FOOD DISPOSER h FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK I - - i - LAVATORY ROOF DRAIN _.-: , SHOWER STALL . SERVICE 1 MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES P . — -- OTHER WATE ING ®__ ® 111 - OAR INSURANCE COVERAGE: I have a current-liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES©+ NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D+ OTHER TYPE OF INDEMNITY D BOND D 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 CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT Ihereby certify that all of the details and Information I have submitted or entered regarding this application are a 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 I iance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i - O PLUMBER'S NAME STEPHEN A.WINSLOW ILICENSE# 12298 SIGNATURE � ",.Z MP +D JPD CORPORATION©+ # 3281C PARTNERSHIPD# LLCD#I I 0 J ,--0COMPANY NAMEI EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE ''o CITY SOUTH YARMOUTH ISTATE MA ZIP 02664 TEL I508394-7778 ` - y' FAX 508-394-8256 CELL N/A EMAIL accountspayablend,eMinslow.com ARE}- 3 Saa 1104 VVIIIMM.P. 1.4N1III VF) 1.nMJJH4I•NJ.4N 1F_w== Department of Industrial Accidents ' ` ., =,.'nim ft Office of Investigations • _,1 1 600 Washington Skeet _ • Boston,MA 02111 ft `a IA www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers .pplicant Information E f /�, Please Print Legibly ame(Business/Orgg�anization/Individual): L,t'.Whet51OW YtU,w,b L vita-tie Ce, int• ddress: ' Keocicdn Chace. OY ity/State/Zip: So,l Ycr,,,.r,,,kn tiA Phone#: %5-3q`i-13?9 re you an employer?Check the'appropriate box: Type of project(required): I am a employer with••70 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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 JI 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' comp.insurance required.] 13.0 Other applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • ieowners 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 mation. /� � 1 ance Company Name: {1rYpv KJ LOA ZJ`(ctetC4.. C 1/11 ) y#or Self-ins.Lie.#: I'3oai A (� Expiration Date: (—I — ,�Ql ite Address:,3 of k,beeJ f ia•e1 Ci'vdt4 MI City/State/Zip: O.Ll to 7 :h a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). -e 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$250.00 a da a ainst the violator. Be advised ti.t a copy of this statement may be forwarded to the Office of :igations the DIA or insura r - overage yen a:,on. eeby certify un e ains a 'penalties o p•jury that the information provided above is true and correct. uT Date: I a,311 a0y1 , k • I . #: SOL 319• "Ing ?cial use only. Do not write in this area,to be completed by city or town official k 1 y or Town: • Permit/License# iing Authority(circle one): loard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector � )they 1 ttact Person: • Phone#: '— • i i Pt$ I054 cost-, 56 j . C C -a ]1 .T] 'OO 0 G--) -n T T O000 T � n y . O O v - dam m 0 '^ i 2 % z z 0 0 0 2 rs m %v Z m . m O z O , r r".04`0ro �I10111�e1 c �, K � 000 prm O m m C « � ,.z � rsa z o mmm -n � rzm -z-S- x7- .9 m -apD Y LrJ II '�: — z ❑ CO �m� itd 1-11° p n CO� � Amn o � = y � om � oc� mp � � m O IIIIIIII ij co w m c H _ S -1 v v 0 o m < 0 'A CO c z o =�� m z .n -1 � m ccDim a; 73 7:1 -imz rn K' m D m Q' N '� Z .Z1 C m Z fn I.71 n,,_5 A rid m M 0 y m Z O y m Co Z O O C) al < 0...21, ❑ y p1 = - - m 9 O ro:o- = m � 007, Z m * 0 m K m e- .-O V 0o D dHCm D m CO OZv mm C I-- tO.d. M t COmpN m A -- D -n -Oi m°-' m O a. A -. O m 1 Z -0 O 0 -"- _ m n o. of Z c D I� D O = a _ m m .O m r m nw OJ Z 73 z cn z o op zz o i II I I mo ,r,0 ❑ m aw m co n m I H k 0 O 9Csg 3 o a c , mGI I = z ad ' 0 d °: < I Ir1'^ m m I I mm ro� z c - Oogm r0 (sD m ~ m O -n ' A 0 II r- O -�. I m 0 m ' c O i I � -o r 25 O 3v a Iin m I, � m~ LON t nan d m ,C 1 1 I mWdc ' 'W r0 N -I T. y Iill A o Li Z � m m oSonI I 1 - t Ccmz v I I CD m d.^ vO m m m I.mmmN n m w CY c3. NI DOmv m ' ICO 65 d N v ' GI p m 3 N0 mi ID mZ vmm ` IJ &II z 5: ii rT1 C7 'o F v an m v II i 0 - m^ n C a A ;I I O 2 O N H m m Z 5-, d m m 9=17) - - - - � L Mil cn % m OT. g c ❑ WO 1 I 1 I �1 m lie i'li rn r cr m l 1 cn ❑ z mm r a 1 I I c —Zi O .tea mm 0 O ( I O 3t m1 O �' z a • 721—I V z m I] Ici &o Z v N HHI II ii co y - 11111 m o o ❑ .11 d ` trN �_� O Z i i 1 i-l 1 l 1 l _ ❑ �'o —zl O 1 I 1 11111.- ❑ m U' _ W a M. {iNIW VI/ /.Irt.soon•Vf t ara ,j s seour.0 1 • y�\ ) ew== / Department oflndasirial Accidents =Aim.--a- • ' Office of Investigations i. = 1`+- 600 Washington Street ' Boston,MA 02111 1/4`"`� www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers applicant Information c Please Print Legibly lame(Business/Organizationtlndividual): E.c.W1ki0 ek�lo- £ l " • to �,� c.., in�. , .ddress: $' &eoaty, eigrie. • ity/State/Zip: Scs%n %arw„c,.A4,, hitt . Phone ii: 5)$-3R9-jqt e you an employer?Check the appropriate box: I am a employer with 70 4. 0 I am a general contractor and I Type of project(required): 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.t 7. ❑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. ❑B ect ng addit on required.] offcershave exercised thew 10.❑Elctricalrepairs oradditions ] 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 HI must also fill out the section below showing their workers'compensation policy information. ieowners 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 sub-contractors 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. ance Company Name: � t ioiteAtato t l its, y#or Self-ins.Lie.if: t$a i AExpiration Date: (-I — a019 iteAddress: fn �.,.r.ie 1, "°� �t�*t� I�1� City/State/Zip: 0,441o? :h a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). •e 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..t a copy of this statement may be forwarded to the Office of igations . the DIA for insura• - overage verij on. ere&certify un a ains a 'penalties o "jury that the information provided above is true and correct. �� Or Date: I - i Loh " ••\\..4 #: .2)g:3`i1. 777E 7cial use only. Do not write in this area,to be completed by cit,or town official • • y or Town: Permit/License# ting Authority(circle one): \ :I loan!of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector )ther ttactPerson: Phone#: • a