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HomeMy WebLinkAboutBLDP-18-005481 • ". MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK j 1= CITY Vali Yn?�r1r 1• I MA DATE t 3 9 /971 PERMIT#/ P-l$ ,2[ ? JOB�fE ADDRESS 33 /l/,s.(i Y-,j r(7;OWNER'S NAMEC V irfid I p OWN :R ADDRESS 1//Y7 '71 -7PC1{,1 - I TEL! . g `g/ .071FAX 1 I TYPE OR OCC( PANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL[IN PRINT - %) CLEARLY NEWL RENOVATION:© REPLACEMENT: PLANS SUBMITTED: YES 0 NOR- FIXTURES 1 FLOOR–► BSM •1 2 3 4 5 6 7 8 9 10 11 12 13 14 a-VICE _ -- 11- 1(1 MAW ._.t I .. CROSS CONNECTION BATHTUB DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAM SYSTEM M. I DEDICATED GREASE S STEM --C DEDICATED'GRAY WAT?R SYSTEM 'Immo— DEDICATED WATER RCYCLE SYSTEM 11111111Mig uppipmpulping isilli .— . . DISHWASHER -� ' _ i DRINKING FOUNTAIN _ '� •• ,i FOOD DISPOSER ...� FLOOR/AREA DRAINI INTERCEPTOR(INTERI IR) ' n KITCHEN SINKc. •• • t _LAVATORY __ :. ;.. ._ i ROOF DRAIN ;._ ,,,.;• • SHOWER STALL .11.14=111 r. 7 r_ SERVICE I MOP SINK _ 'NM MR 1.11.1140111 11111114111MiiiiiiiM __ - 4,- 4 TOILETt URINALznowl= Agniiiiimw f WASHING MACHINE C f_NECTION � WATER HEATER ALL T"PES ' - -- WATER PIPING _ _ OTHER (- M. i . . ..., ow �m r�s.iaat.. . . iS_._— .�Si . INSURANCE COVERAGE: I have a current liabilir insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 1 NO ID IF YOU CHECKED YES,LEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY!NUANCE POLICY ID OTHER TYPE OF INDEMNITY 0 BOND 0-•• OWNER'S INSURANC :WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Gener I Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER® AGENT 0 _ SIGNA'URE OF OWNER OR AGENT I hereby certify that all c the details and Information I have submitted or entered regarding this application are toe and accurate to the best of my knowledge and that all plumbing wrk and Installations performed under the permit Issued for this application will be In Hance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. //i %/G-14--/e4121.-44.1-.641 - PLUMBER'S NAME S'EPHEN A.WINSLOW !LICENSE# 12298 SIGNATURE . MPO JP Di CORPORATION0# 3281C PARTNERSHIPO# LLCO#M COMPANY NAME EF NSLOW PLUMBING&HEATING I ADDRESS)8 REARDON CIRCLE 1 • CITY SOUTH YARMCJTH 1 STATE WIN ZIP 02664 __ - TEL 508-394-7778 FAX(508-394-8256 CELL 1 NIA I EMAILaccounts aable efwinslow.com = ,_ - Office of Investigations . 600 Washington Street *; _= Boston,MA 02111 • www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers • Applicant Information C Please Print Legibly E game(Business/organization/Individual): , •W r,hS o,�i Pto.... "c L lett. Address: Ke ouan City/State/Zip: Soy,•rv\ yi7ro.,c,,,k1 µA• Phone#: '501- 3c14 11'7 ire you an employer?Check the appropriate box: I am a employer with '70 4. ❑ I am a general contractor and I Type of project(required): . 6• ❑New construction employees(full and/or parme).* have hired the sub-contractors t ti ❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working tfor 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 10.11 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 12.0re insurance required.]t employees.[No workers' • Roof p comp.insurance required.] 13.0 Other ny applicant that checks box 111 must also fill out the section below showing their workers'compensation policy information. lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. mtractors that check this box must attached an additional sheet showing the name of the Ab-contractors and their workers'comp.policy information. tm an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site formation. surance Company Name: ‘.^) ( k.1htctA ,,t tt "e1y • ilicy#or Self-ins.Lk.#: I 2.a I A Expiration Date: —1 — apt') • b Site Address:a3 c' ire .11 LtNegAy4 NI City/State/Zip: DOW(,7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). inure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a to le 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 'up to$250.00 a•: a:ainst the violator. Be advised ,at a copy of this statement may be forwarded to the Office of vestigations . the DIA for insurap overage ve ', on. i to hereby certify u it ,e airs , ;penalties o jury that the information provided above is true and correct a•a / , nate. (a i a0154 gone#: SI)St•214- 777 ' Official icial 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#: • • /?-? P