HomeMy WebLinkAboutBLDP-19-005140 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBINGG WORK k�
,"a 1:= ` CITY - -__ 7_-.-_. __ . • I MA DATE L 1 .1__.Ti PERMIT#/6rDf' -0d 57T
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q`_ JOBSITE ADDRESS f 1�. _ 'ptatii,_ fi NC;_ OWNER'S NAME I ShCt R�I i f- - s
POWNER ADDRESS ..�?iq in�� ___ TEL15Ll.. 2 , IFAX1-.-.._-___-___-1
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL EK
PRINT PLANS SUBMITTED: YES 0 NOD
CLEARLY NEW:CI RENOVATION:0 REPLACEMENT:
FIXTURES Z FLOOR--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB NM
:-
CROSS CONNECTION DEVICE � —
DEDICATED SPECIAL WASTE SYSTEM 1
DEDICATED GAS/OIL/SAND SYSTEM IMI
DEDICATED GREASE SYSTEM
NM
DEDICATED GRAY WATER SYSTEM .. _ _._ -_- �� � MA -'
DEDICATED WATER RECYCLE SYSTEM - __
_.
i DRINKING FOUNTAIN
-- DISHWASHER
r FOOD DISPOSER _
' _ _ inini7inung _ _
.__ FLOOR 1 AREA DRAIN _
y INTERCEPTOR(INTERIOR) ®igigin
KITCHEN SINK
—
' LAVATORY
•
ROOF DRAIN WWilli -
SHOWER STALL
SERVICE 1 MOP SINK milisi
TOILET _R
URINAL
WASHING MACHINE CONNECTION MI MI, MO
_
WATER HEATER ALL TYPES
WATER PIPING
_WWII
OTHER - � in NM 1111111
I I
INSURANCE
I have a current liability insurance policy or its substantial equivalent which meets requiremen
ts of MGL Ch.142. YES Ei NO []
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY Q 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.
Ci— CHECK ONE ONLY: OWNER [J AGENT D
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 nd 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 nce with all Pertinentnt�provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �C�^�✓!/v!/ c---
PLUMBER'S NAME STEPHEN A.WINSLOW ^� _ T LICENSE#112298 —1 SIGNATURE
MPO JP CORPORATIOND# 3281C_ ._ PARTNERSHIP#I______--__.__)LLCQ#1�,._ 1
COMPANY NAME EF WINSLOW PLUMBING&HEATING _ ADDRESS 18 REARDON CIRCLE__-T ___________I
CITY SOUTH YARMOUTH _ STATE _MA ZIP 02664 _ TEL 508-394-7778 ______________1
FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com
6 a'
d 166. 6-,6/D00.00 6D/115 Pr.yy66D6 VJ 1..Q66JJ666.Db66.DZ60.J
Department of Industrial Accidents
e Office of Investigations
-,.i1
=�� 600 Washington Street
` � Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
)nlicant Information Please Print Legibly
tme(Business/Organization/Individual): £' .Iir (O M Q( t k iiii 1 0�.eo_\'
Idress: P art Citt.Ie— (J
ty/State/Zip: So%s-cA'N 'r -'c,,At,., NA- Phone#: 5O - 399' 717
you an employer?Check the appropriate box:
Type of project(required):
I am a employer with -7O 4. ❑ 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.$ 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance.
[No workers'comp.insurance 5. ❑ We are a corporation and its 9 ❑Building addition
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. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.0 Other
Lpplicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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sowners 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.
to employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
nation.
tnce Company Name: .,.y (` utliall e1,,i`C el C
I#or Self-ins.Lic.#: I7,at A-
Expiration Date: (--I — aOt9
to Address:�J Ltlnr�r+�cv)yi-e0-14 L1 Q Cke 1 I
City/State/Zip: 0,)4 to 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
3 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
.o$250.00 a da against the violator. Be advised ttat a copy of this statement may be forwarded to the Office of
igations • the DIA for insurar• overage veri •, on.
;•
ereby certify un e e gins a i penalties o •'filly that the information provided above is true and correct.
uT:: � N1
up. -' ' ,.. . Date: t i aoli
#: . jg:351- 77g
icial use only. Do not write in this area,to be completed by city or town official. sa ar
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V % \•) '
y or Town:
Permit/License#
ling Authority(circle one):
Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PlumbingInspector ..
►ther ,�
tact Person. t ') k Phone#: `
414- 1