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HomeMy WebLinkAboutBldp-19-005840 • r� PERMIT# 51%Q t-F=. ; CITY p 1,--�---- a-,��mi��a� MA DATE _ JOBSITE ADDRESS i is tbQ 1 W 11 4(' _ r IMOWNER'S NAME OWNER ADDRESS _a S a 1/_1 c�IT 3 �1 TELNW-6 y- Y FAX it TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW D--RENOVATION:D REPLACEMENT:FA PLANS-SUBMIT-T-EDYES-0-NOD-_ FIXTURES 1 FLOOR-r Qum 2 ©0© 6 7 8 9 10 1111® 1111121 _BATHTUB , 10.11111111111111_ W___ bkm CROSS CONNECTION DEVICE NM 1111111IMIMMIIMMI111111111.1.111 I Cy=4. DEDICATED SPECIAL WASTE SYSTEM 'mei DEDICATED GASIOILISAND SYSTEM ` y L1 =W i 1 I WI MIN DEDICATED GREASE SYSTEM MENIMINE W_ L-M11111. DEDICATED GRAY WATER SYSTEM � -__`-___�` _ �DE0 DICATED WATER RECYCLE SYSTEM ll�_ I .___I_- _ l DISHWASHER _I01M - lam' ' 6-2 DRINKING FOUNTAIN I _ FOOD DISPOSER 1 a 7--- 111. FLOOR I AREA DRAIN —� --aluilaitioi _ INTERCEPTOR(INTERIOR) _I-- L�i s KITCHEN SINK [WMilli LAVATORY I_ �� iiiimunivisii ROOF DRAIN _ -I W i SHOWER STALL � '.� ,I�IM �� l 1 _ I� W WW - -- � lilt 1 " SERVICE 1 MOP SINK �I„ _TOILET �'� r 'M�� URINAL — I _ EW WATER HEATER ALL TYPES 1 : WASHING MACHINE CONNECTION �( WATER PIPING ! ���1����,�I� '��r---- OTHER �• - v --- - - r.. -. ..., , •1 I - — R. I INSURANCE COVERAGE: a— I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES�r__ NO Q ' IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El BOND U 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 C AGENT U SIGNATURE OF OWNER OR AGENT 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 corn I' nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMESTEPHEN A.WINSLOW __ LICENSE#1:12298 _ SIGNATURE MP El JPU CORPORATIONO#)3281C __IPARTNERSHIPD#I_____^_ILLCD# COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 18 REARDON CIRCLE__ _ ____ I CITY SOUTH YARMOUTH - STATE MA ZIP I02664 �___ _ ___ I TEL __ �____ _____1 FAX(508 394 8256 1 CELL N/A EMAIL I accountsnayablet�efwinslow.com _ - �Q ,b0 &y a^"^� a v66. a..v/vbrv • 6Cl/6 IY6.0 0.6vb 0/J lI.Q669066L/b66136.6619 * Ii'epartment o � Industrial accidents Office of Investigations TAj_ 600 Washington Street Boston,MA 02111 WWW.mass.gov/dia Vorkers' Compensation Insurance Affidavit:Builders/Contractor-g/Plectricians/Pl em- leant=Information, b Please Print Le 'bl (Business/Organization/Individual): E•C. ass: tea„y -,rap_ • Mate/Zip: eu-riAl cr-v-tti,tt„ ;A Phone#: 5)3-394-7`i'/ a an employer?Check the appropriate box: un a employer with '70 4. 0 I am a general contractor and I Type of project(required): aployees(full and/or . have hired the sub contractors 6. ❑New construction part-time). an a sole proprietor or partner- listed on the attached sheet t ip and have no employees7• 0 Remodeling ip and fory e in anycapacity. These sub-contractors have P ty workers comp. ' 8. ❑Demolition .o workers'comp.insurance 5. p insurance. 9 ❑Building addition luired.] 0 We area corporation and its m a homeowner doingall work officers have exercised their 10•0 ElectricaI repairs or additions right of exemption per MGL 11.0 Plumbing repairs or additions 'self.[No workers'comp. c. 152 airance required.]t 1(4),and we have no 12.0 OtherRoof repairs employ ees.(No workers' comp.insurance required.] 13.0Other ant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. rssployer that's providing workers'compensation insurance for my employees. Below is the polic and job fat y � site Company Name: y (-l`i r Self-ins.Lic.#: I$a i Expiration Date: 04- I • ddress:. 3 Gnnme�wee-41-1 — ��e -----: :-------A-------A " City/State/Zi : (,p � opy of the workers'compensation policy declaration page p—� 7 secure coverage as required under Section 25A of p s; (showing the policy number and expiration date). 61,500.00 and/or one-year imprisonment,as well as�G�1 penc. 5alt2 ieasnin the°the position of criminal penalties of a 50.00 a day against the violator. Be advised ttat a coform of a STOP WORK ORDER and a fine Nis at the DIA for insur.r• overage veri on.copy ofthis statement may be forwarded to the Office of , +Cer"certifyuK e e aiats a I penalties o p-,jugthat the information provided above is true and correct. __ Date: is i : aoli ase only. Do not write in this area,to be completed by city or town official i = '�• ?��� 'own: • Luthority(circle one): Permit/License# of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing mbmg Inspector I 'erson: \ Phone#•