HomeMy WebLinkAboutBLDP-19-004897 ' y /
\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS i
l sezej )s��cy �- . OWNERS NAME -S E ci . ,„ ___,t
OWNER ADDRESS!j s tEL
P Il/_ ot's� lij�B6G dr✓� f'1e2� TEL[ .3t 3�0 FAX[
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL I.21 RESIDENTIAL Ea
PRINT
CLEARLY NEW: 71 RENOVATION:Ey REPLACEMENT:2 PLANS SUBMITTED: YES fl NOD
FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1 - 1. . I --7[ I--'' 1--:`1C 1- 1 1 _... f
CROSS CONNECTION DEVICE I 1 [- ( --''I --` I .1
DEDICATED SPECIAL WASTE SYSTEM I 1 [-- I---1 — ( (} ( 1 r
I —:11---
-
DEDICATED GAS/OIL/SAND SYSTEM I .-...:a I=_ j- I F 1 [_ ,._ 1 , f -.::.f I, .., I--~
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM -
DEDICATED WATER RECYCLE SYSTEM I 3I !- ! - ---i 1--- --- -•--,
r r _ I _ , , 1 ► I
DISHWASHER r- 1 1 u -. _ 1 I_ �: w_
1 1
DRINKING FOUNTAIN I I__ r_ - ` [.,� (�.. +.
FOOD DISPOSER -' R
�r, ! I . ! I I f C ( l f I
FLOOR/AREA DRAIN I_"_ j I I { I
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY ! I ; -
1.. l.-.. _
ROOF DRAIN 1 i I. 1 �+ i- i [ 1 i i. _.._
SHOWER STALL 1 I 1 l ( t� I 1
SERVICE 1 MOP SINK _ - --- --_ 1---.---------_- ---. _
1 i._. . E. ., i i . i..., I l i . I _ [.
TOILET I. f I_ ( I [ 1 I [ } I
URINAL [ I I - - [. I 1 I I } [
WASHING MACHINE CONNECTION f i I I I ( I i I
WATER HEATER ALL TYPES I / I I — !_ - - - - i r-
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WATER PIPING , rN
OTHER 1 I i I i - I 1 r
=: 1 INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES '. NO [ 1
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I„ld OTHER TYPE OF INDEMNITY III BOND El
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 1-21 AGENT [71
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 comp!. ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - ���
,...,_
PLUMBER'S NAME .STEPHEN A.WNSLOW I I ___ _
-�- - ;LICENSE#[.12298_ __ SI ATURE
MPiw JP CORPORATION S#13281C�__ IPARTNERSHIPI�W#f_ . . LLCL_"#,'^ _ .
COMPANY NAME _E F WINSLOW ADDRESS 8 REARDON CIRCLE I
- - - �. —
CITY SOUTH YARMOUTH i STATE[ MA I ZIP 1,02664_� _�` 1 TEL[508 394 7778- _-
FAX 508 394 8256 #CELL 1 EMAIL ACCOUNTSPAYABLE EFWISNLOW.COM '� 1
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A Offiee o 1(Favestiiaaaor&s
600 Weldragfroa Slre
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Workers' Compel'.salon itic u enace davit:Baderes/Contrcact®res/T leetsrnenm s/. lulloabe:rs
'k tacant hiformatnoiin Please Pit Legibly, ..
Tarrle(Business/Organization/Individual): e dc.WI evu Q(U„kkto t ci &to.e.ct..t-t c�_4 1�1c o
4ddress: aeaiun
City/State/Zip: So,I••%/N Y w+cs r MPr Phone#: -Y19-1` 1V
ire you an employer?Check the appropriate box: Type of project(required):
.rI am a employer with '70 4. ❑ I am a general contractor and I 6. ❑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.1 7_ ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑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
I am a homeowner doing all work , right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. o.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 bax41 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 anew affidavit indicating such.
:ontfactors that checkthis box must attached an additional sheet showing the name of the sub-contractors:apd their workers'comp.policy information.
m an employer that is providing workers'compensation insurance for niy employees. Below is the policy and fob site 1
i f ormation. n� _� � ) •
ltsurance Company Name: 4�iYYO / c J In/0.11 1S't.K4 el(Q, •Celfv•NX..vvi
Day#or Self-ins,Lie.#: k 5.I A- Expiration Date: --1 _ Ddn •
}b SiteAddress:DJ Gnr\rvI& w-en--1 )r One I 1 City/State/Zip: (:),)ki 67
.ttach a copy of theworkers'compensation policy declaration page(showing the policy number and expiration date). .
allure to secure coverage as required under Section 25A of Ma 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 d y, gainst the violator. Be advised that a copy of this statement may be forwarded to the Office of
ivestigations the DI for insurarreTverage veri canon. ( .
do hereby ad un e e ains an penalties o pe jury that the information provided above is true and correct
i>?natu • '"- (A/A, Date: Val 3 I I a01.
hone#: , •3114- 777g .
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#:
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