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HomeMy WebLinkAboutBLDP-20-001144 r—� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK = � 08/27/2019 /L /r' CITY/TOWN YARMOUTH MA DATE PERMIT# /��/' �© JOBSITE ADDRESS 10 BLUEBERRY PATH OWNER'S NAME MCDONOUGH, CAROL OWNER ADDRESS YARMOUTH PORT TEL 617.877.5560 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:® PLANS SUBMITTED: YES El NO p' FIXTURES- FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[11' NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY l' OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 El AGENT El 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 co lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. j PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 _ SIGNATURE MP Q JP❑ CORPORATION['# 3281C PARTNERSHIP El# Lc El# COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspavableaefwinslow.com WORK ORDER 511175$40.00 / p-h/6 /, . • if - - r e i n*010:u 04.4 nfs m �' : 1 J'arlS AI: 100 Boston,fi4 021144017 ,iii Y .4. L. jvwWr 'sgov/tea - trortoslLap ne _1a.t: ttaa n .ca fdi"* SiUders/Gontc rs< le cans/jumteis. �90l t 11`1 1r �At O> ;.. ' g' r ion 11 <� egbli .\C , E.*ti.NiN LOW S PI UMBING5&HE rJNG CO,.JN = 1 + .« tffi# ef 1 I sna � with lo ( iltand/or partmime).+ 7 ]:New ctfstru dion R[ qt **:to enoto*notopCoyd, otkiae o is ' ao1�cwr0 tOinet tekiti4idj 4 ` P0 01.0.1 v4lf� 0.4 „ ! nsurac ulnsi( 8 it 4fitg 9. L.4 D eitton l i+ .,,,, ,,, , ,a +ll t� nt�wtotrt Oftiductau virerkottim I b 01, Lt0'►S sad i 11 �� Y ISW rtX*I will ti�tl E[�.CWl1tj€eri7 C6t1pasQbWl;lt1#1lTpgfSOFllr!¢.S,tIE' I 1 1}Y R�,f+f11Q; f !Qb6•r. " Eft . 1. .�.Plutnb g*paiirs"or. ott8 51:300ta tsq, ::- -ti It lhi i Oh tti S ` ¢7 itice: b abii ve•workcrt au 13.�} Oof.- s itosub�o.Itaa I '` hs i aut e= L.. .. - _ O d i� lu*t .. -e+ 9l sad•tfkm't 11t!o.**.*tton MOt.,o: l4 0 tbs `15miak)id 41sP/4:uoS loyc;tlgt workers comp;rr ertgttb d:) 1 �til tLb i O'iiiililhc od ets ccori0431 0 hc y� ** 40.0"001y cItg W aldk mhumbottstcbhab 100tO tiai Watt t}ing$u i.**. n toatsdt`khcrwltgThenpahsontato*a dal1te wwhct1etonoxe ilflsvq_.r - l „0lt ,±ar prot?tttn wcirkeee cornpensattan Insurance for tijreb iR ee&. Bethw1s-thepo`! an71b,0, e: r jbnttor ;91 ' tALR 91N MUTUAL IN 1,RAN COMPANY • - Policy#ter l dome:L C #x 9 9A- EXiiirnt►on De c 011012 20 Job it .b . . - :*;Grty/State/Zip., - <. w., A1taeh a togs,iu'f 'compensation pork deiartitiion page•(tbowing•the poitcyuumber and Laic Iii0ay1latr: Fats n eip **Os. u under 1vIGL it:152,f25A,is-a thnlnal vtotattott_punishable by a fine up to :00 OQ- - ansUor. n�c1iiir npri nnlent,as WOO as cw:il penalties to the form of a STOP'WORK es t► .. o a hurt t f u, to; t50 00 a: clear a**V-0.atOL A off statement may be forwarded to the Offi"s a of Inv stigations ofthe t�0 n wtanoc - ce.. . _ -i`?' 1 • ,tF �� _ it yyiiii .zr aa, y; �i,tom '�.ia iiiii'� ,t �, :, a. /.-t,Y" ��f F'�J. d (F r u of �. that the � aII( j rb r bove ii' 6'�Ni(F iv Sys. a +:,ir5- r Date 4; . fi at o4r,b otw 4 his area,to be compf eil by 0,4,•oriown n,/1Ci Jrt'L Clty.or'ToWm: ._ -. - Permit/License • • # . .. • 4 . dI`a #0 ilidtrittlO rt teitt 3..City/Tow n Clerk: 4.;Electrical"In$pertor•5 Pli iimmb`ing: .eCtor Coi�tgctpersQ �. w " Phone,