HomeMy WebLinkAboutBLDP-19-002969 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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�_Tt�;� city YUfrn/ry I MA DATE' 11 IB/iR PERMIT#/310)119-00r2969
JbBSSIIT6EA 3 RESS 3a Tabaf R0 lie 5-1 Yr0/mn✓Pi 1 OWNER'S NAME! p3/Ad TO A5on
P OUJWNERADDRESS SRYn-C TEL, SUV 11 S 46 7 a IFAXI I
TYPE OR OCUPANCY TYPE COMMERCIALD EDUCATIO D , RESIDENTIALB
CLEARLY NEW:CI RENOVATION:D REPLACEMENT: M-4 PLANS SUBMITTED: YES ID NOD
FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUBi i
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM r r
- _ _��1 -
DEDICATED GAS/OIL/SAND SYSTEM IIIIII
DEDICATED GREASE SYSTE -NWM c
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM Ilia-
DISHWASHER
DRINKING FOUNTAIN --
FOOD DISPOSERf
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) IF r +•
KITCHEN SINK
r
LAVATORY . _
ROOF DRAIN
SHOWER STALL gm
SERVICE I MOP SINK IMES. . I "
TOILET
URINAL -.
WASHING MACHINE CONNECTION
WATERHEATERALLTYPES I
WATER PIPING
OTHER _
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1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NOD .
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND 0
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 Q AGENT Q
SIGNATURE OF OWNER OR AGENT
0 I hereby certify that all of the details and Information I have submitted or entered regarding this application are tr 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 • .nce with all Pertinent provision of the
% • Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 'sr efyf C )
O PLUMBER'S NAME'STEPHEN A.WINSLOW !LICENSE# 12298 t SIGN/jNATrUJPQRE
`p`f1 MPD PEI CORPORATIOND#I3281C IPARTNERSHIPD# LLCD#I I
(O COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS!8 REARDON CIRCLE
„i3. (3" SOUTH YARMOUTH STATE MA ZIP 102664 TELI508394-7778 1
C\_.r FAX 508-394-8256 CELL N/A EMAIL'accountspayable@efwinslow.com
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SILZ1/4 A/OA t.VIIIIIWISII4SSOIO IA) t.{4JJ44Ii MJ464a {,-\
Department of Industria(Accidents `
). _ 1_ l Office of Investigations
._,iia 600 Washington Street
Boston,MA 02111
r'� www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.nnlicant Information Please Print Legibly
.ame(Business/Organization/Individual): E•C.Wt��p,N �O,ybi g t0. &) Qe, 1^(a
.ddress: 3 Gori ✓, Circler
ity/State/Zip: Souk Ycrwc,.rt1n Mfg Phone#: '$()5-399-71'n
e 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. 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. 9. ❑Build ng addition
insurance 5. 0 We area corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
II 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.
•
Leowners 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
matron.
ance Company Name: /'y'oN.,.) 1` hj A rriJINel n C-e. Cr/Vvyt,iy
y#or Self-ins.Lic.#: 1 S a I A'
�(^� Expiration Date: i--1 — adlC.'
G
iteAddress:a3 Mr vreo.i4h A4 4/ C e,31.6l' M1 City/State/Zip: O,)11to7
:h a copy of the workers'compensation policy declaration page(§howing 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 I the DIA or insura r - overage vert a'on.
ereby certify un - e ains a penalties o p-jury that the information provided above is true and correct.
!n4:. -.
Date: la 1 aoh
#: sb%:319. 7�7g
?tial use only. Do not write In this area,to be completed by city,or town official. I�
•
y or Town: • Permit/License# 2V
ring Authority(circle one):
board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
)ther
'tact Person: • Phone#: \
' V