Loading...
HomeMy WebLinkAboutBLDP-17-005018 StJ, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _bl=.;' CITY ' 5 /17 „ IMA DATE Ifig fes./21 P RMIT# Gam/ ' /—// I/ ; • JOBSITE ADDRESS 2 (.4M-A0.9 — IOWNER'S NAME. p OWNER ADDRESS II! ,//I / inl .Ara TEL raWr i s,� AXI a TYPE OR OCCUPANCY TYPE ; < COMMERCIAL© EDUCATIONAL 0 RESIDENTIAL PRINT DZ.- , / - CLEARLY NEW:© RENOVATION:© REPLACEMENT:Ild' PLANS SUBMITTED: YES 0 NO PA FIXTURES? FLOOR-. 631,1 -I 2 3 4 6 6 7 8 9 10 11 12 13 14 BATHTUB I 1 i I ..1., ir i CROSS CONNECTION DEVICE 'ilillitaiiiailtailtaifitiallite • DEDICATED SPECIAL WASTE SYSTEM Sngsnain 'IeageSriJ DEDICATED GASIOILISAND SYSTEM INIAMNialleall,y�siq s !wss! DEDICATED GREASE SYSTEM 6 S ���;���� DEDICATED'GRAYWATER SYSTEM a' i � .i:Si •s s DEDICATED WATER RECYCLE SYSTEM �rionimaiipplrnilra DISHWASHER SISn.S.1Ias•ia1111 DRINKING FOUNTAIN S 'S MIS 'SSS FOOD DISPOSER • ISIMINSIS . lIMINIIIIIlMSAIN FLOOR 1 AREA DRAIN SSIMISIONINIIMISNIONSIIINIMINNSIMISIMBIll INTERCEPTOR INTERIOR MISSISSIIIIIINOWItilmilleiiiamitterligig LAVATORY SST KITCHEN SINK RRAN OOF DR SITALL � SERVICE 1 MOP SINK _MaaPat a5ISS S:S IO TOILET • .SIIIIIIMPOINICSinIMILIM URINAL -IIl .NtIM - r WASHING MACHINE CONNECTION I5 S ' n' s raisin WATER �'� �, �1�MO aN. WATERPIPINGRALLTYPES —nes r 5�IMEsnss OTHER � iiiiii � � -Q-: 4---_ 111.11110110SISSISSIIIIIINCINIMISSIIII11111S1111111 --%4 JilaillitiiiiSIMMOINNialltillialliallaliglitIllnillt NNW INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YESC0 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILTY INSURANCE POLICY ID OTHER TYPE OF INDEMNITY 0 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 0 AGENT 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 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 inc planes with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. S.V PLUMBER'S NAME l STEPHEN A.WINSLOW ILICENSE# 12298 SIGNATURE MPE3 : JP® CORPORATION# 3281C •PARTNERSHIP[2# LLC©# • COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE I CITY I SOUTH YARMOUTH ISTATE list ZIP 02664 - _ _ _ TEL 508-394-7778 FAX 508-394-8256 CELL NIA EMAIL I accountspayable@efwlnslow.com _w__= Department oflndustrtaiflccwents 1c c: RES.y Office of Investigations =::e= ` 600 Washington Street =`1a- t Boston,MA 02111 • ^�,., .;o www.mass.govldia ' Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� Please Print Legibly • Name(Business/Orgganization/individual): E•C•W+, n5�ovJ YtV0.4.10iet.j 2... kitciA , co, Ifit• Address: QP� c.E.iL Q t , CIta City/State/Zip: Sookh n'-cs..kn 1413c Phone#: e5Q .3c19r177Cd • Are 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 6. 0 New contraction employees(full and/or part-time).* have hired the sub-contractors :.0 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'camp.insurance. 9, ❑Building addition [No workers'comp.insurance 5. 0 We are a corporation and its 10.0 Electrical repairs or additions required] officers have exercised their 1.❑ 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.] thy applicant that checks ha#I must also fill out the section below showing their workers'compensation policy information. Homeowners 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. tint an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 1 ts`brmdiion. /n __ ff (� usuranceCompany Name: Anm?i Mvw� un Pt-Q ` t p e nl alley#or Self-ins.Lic.if: 1 S a 1 A • Expiration Date: c-1 — bol-j rb SiteAddress:d3 CbMrexcv . ea-t%h Ad`tI ChZ3114411 Ili City/State/Zip: Oa A-1 417 .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a ne 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 Cup to$250.00 a da a_ainst the violator. Be advised i•t a copy of this statement may be forwarded to the Office of • tvestigations i the DIA for insurer 'overage veril on. t do hereby certify un• •penalties o cifjury that the information provided above is true and correct. a •• 4 ` bate' [a t a01( hone If: SI)1•35`1- 777x Official use only. Do not write in this area,to be completed by city or town official • 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 if: '