Loading...
HomeMy WebLinkAboutBLDP-19-003524 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '4 _ Jett} Y&roll Oil ' J MA DATE II/5/le (PERMIT#/k-01?-0(15a9 CITY JOBSITEADDRESSIISCAPfain Yft,)I Rd Sad'h I OWNER'SNAMEI Chris/1a Psuk I V�21 P , OWNERADDREAk SSI St~ms TEIOSGcZV 521'1 IFAXI 1 �G0�� TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL (1 PRINT /" CLEARLY NEW:© RENOVATION:© REPLACEMENT: PLANS SUBMITTED: YES© N00 UI n I FIXTURES 1. FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUBJr CROSS CONNECTION DEVICE _ DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GASIOILISAND SYSTEMRIM. r - DEDICATED GREASE SYSTEM _ - DEDICATED GRAY WATER SYSTEM . DEDICATED WATER RECYCLE SYSTEM - DISHWASHER • DRINKING FOUNTAIN • FOOD DISPOSER 1 s I - . FLOOR I AREA DRAIN r �, - LAVATORY INTERCEPTOR(INTERIORKITCHEN I, I. �, : , ROOF DRAIN I r a SHOWER STALL SERVICE I MOP SINK • TOILET - -- -L — URINAL WASHING MACHINE CONNECTION I -,a MEI- -,, --, --, 7 . n, ,_ WATER HEATER ALL TYPES WATER PIPING !s I OTHER- 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESO NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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 0 Q SIGNATURE OF OWNER OR AGENT cs, I hereby certify that all of the details and information I have submitted or entered regarding this application are t and accurate to the best of my knowledge • s and that all plumbing work and Installations performed under the permit Issued for this application will be In co lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ti� �, PLUMBER'S NAME�STEPHEN A.WINSLOW (LICENSE# 12298 pieSIGNATURE (.._/ MPO JPD CORPORATION O# 3281C PARTNERSHIPD#1 ILLCD#I re% r COMPANY NAME)EF WINSLOW PLUMBING&HEATING ADDRESS,8 REARDON CIRCLE I Cp CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 1508-394-7778 1 4 FAX 508-394-8256 CELL N/A EMAIL accountspayablenaefwinslow.com Ia 1164 �VIIH•wo•rrs s••••u t.1W)JHYI.MJi6W Pk __t= Department of Industrial Accidents ' l— l Office of Investigations - _1`-=,. 600 Washington Street • Boston,;MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers .nnlicant Information Please Print Legibly ante(Business/Organization/Individual): E•c.w kt0tm Y1u,n,Ipt✓t3 L t to-1- Qe) dint, ddress: '3' Qpot�ttn ( 10.42. d • ity/State/Zip: Six'k '/c't'v'-,c,.,kh t4ftr Phone fl: %8-3q9-11en 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. 9. ❑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 ] 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 R1 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 oration. //�� 1 ance Company Name: y7Yypv,.) t`kvi-G0—#3/4 �1 nrtwetnt.t Cettnt,ni y#or Self-ins.Lic.#: isa I pr �(^" Expiration Date: (—( — a019 iteAddress:a3 Cn"n3.1t,µeJ4Lh I GR,364. 11111 City/State/Zip: Day 1,7 '.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 t,.t a copy of this statement maybe forwarded to the Office of :igations ' the DIA.or insura. - overage veri'on, ereby certify un • /e aims a penalties o •jury that the information provided above is true and correct. `u4.• / L Date: la I amt " #: cb1:35`i- ri9?g • ficial use only. Do not write in this area,to be completed by city or town official - y or Town: Permit/License# ' ling Authority(circle one): • •.,::::::„....„ loard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector1 )they :tact Person: • Phone#: 1 weir-id CITYI YQ/1110U4-1-. I MA DAT: faill PERMIT# I' I2 5/ - JOBSITE ADDRESSI115 AA;h Sin/il V SOVfh 40404 OWNER'S NAME' CW i f Pit P40 k 1 • OWNERnADDRESS I 5Gn( ITEIl5081.4662'11' IFAXL TYPE OR OCCUPANCY TYPE COMMERCIALDEDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW.D RENOVATION:D REPLACEMENT:E PLANS SUBMITTED: YES[' NOD APPLIANCES? FLOORS-+ BSM 1 2 3 4 1 5 6 7 1 6 9 10 11 12 13 14 BOILER BOOSTER MSS 'SS � CONVERSION BURNER COOK STOVE DIRECT VENT HEATER , DRYER FIREPLACE FRYOLATOR - -. FURNACE GENERATOR _. — ---5 GRILLE = INFRARED HEATER, LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATERr ROOM I SPACE HEATER ROOF TOP UNIT TEST •• UNIT HEATER' - UNVENTED ROOM HEATER - WATERHEATER — --- OTHER —OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q+ OTHER TYPE INDEMNITYD 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: OWNERD AGENT CI 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 in compll a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / +t..> LN�./....t/ PLUMBER-GASFITTER NAME)STEPHEN A.WINSLOW I LICENSE# 12298 SIGNATURE 4.v MPD MGFD JP I:1 JGFD LPGID CORPORATIOND#13281C IPARTNERSHIPD4 'LLC[❑#I I Ln COMPANY NAME'EF WINSLOW PLUMBING&HEATING I ADDRESS'8 REARDON CIRCLE U CITY 'SOUTH YARMOUTH I STATE MA ZIP'02664 ITELI508-394.7778 I FAX'508-394-8256 I CELLI N/A EMAIL'accountspayablenc,efwinslow.com I l!1 M S � ci::, 2..V • lb Le C253 a uo ...vuw.avr,,yq,, du vJ art.un,uerca.uo.w — . DePartment of Industrial ntastriaiAccdfents + _ t Office of Investigations; . ,�l=tyi_ r _ . 600 Washington Street ' . Boston,MA 02111 www.ma Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 1 licant Information E f� Please Print Le.'61 ime(Business/0rgenization/Individual): 1.•1-.',1�s 'pW �,d i idress: ', ,t•atltvi , Q. t r ty/State/Zip: {v% `/ ,,,,,` .a Phone#: 'OE-39`1-7gg4 you an employer?Check the appropriate box: Ty employer with 70 4. 0 I am a general contractor and I riam a emplope of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 7. ❑Remodeling f I am a sole proprietor or partner- listed on the attached sheet t 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 1 9 Building addition required.] officers have exercised their. 10.[]Electrical repairs or additions I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no insurance required.]t employees.[No workers' 12.❑Roof repairs comp.insurance required.] 13.0 Other rplicant that checks bdx 41 must also fill out the section below showing their workers'compensation policy information. owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. dors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. to employer that is providing workers'compensation insurance for my employees. Below is the policy and job site talion. • ace Company Name: jtfcs eit1 — et #or Self-ins.Lic.#: i z a i A- Expiration Date: [—)— app eAddress: _ v,ed C , Zip: t a copy of the workers'compensation policy declaration page(Showingtthe policy number d expiration date). to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a 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 r$250.00 a da a_ainst the violator. Be advised t..t a copy of this statement maybe forwarded to the Office of ration • the DIA for insure, - overage veri"on. reby certify un •- -penalties o .• u 7j ry that the information provided above is true and correct. T. ir- AL Date: la i a01- . ii‘ I: 1V : -797; :!a!use only. Do not write in this area,to be completed by city-or town official • or Town: • Permit/License# ng Authority(circle one): .aid of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector :her act Person: Phone#: -NO t.. .