Loading...
HomeMy WebLinkAboutBLDP-19-006584 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ir_: _c/ F; �1_r' CITY ( 4 -i' ..5i- ,f/J - ' MA DATE Wy* i AI PERMIT#glip 00 (/._‘‘. JOBSITEADDRESS 11L;5Li¢ / ),,c OWNER'S NAME lUL.G: T . L P OWNER ADDRESS I % �L,4,c, ✓LC,4& TEL ki D 8.- AffarIPME AX 11111111111111111111 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL E PRINT CLEARLY NEW:0 RENOVATION:D REPLACEMENT:Et' PLANS SUBMITTED: YES 0 NOD FIXTURES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB irit01111 INN® ®''11111111I1111111 MN NON INN____ MIN NMI MIN IIII CROSS CONNECTION DEVICE ®®INN®NMI MINI NEI NNI®IIIII N NMI MNNEI DEDICATED SPECIAL WASTE SYSTEM in im.®m milrEnt mu mg um mug um um min mit DEDICATED GAS/OIL/SAND SYSTEM !MN®',IIIIIIII MN 1111111•0111111®N I NEI NIS MN MI NEI', DEDICATED GREASE SYSTEM 111111.MN NMI INN OMNI INN NON NMI NE NEI NM NMN MN DEDICATED GRAY WATER SYSTEM M'®®NM_,NIIK M N I MN M'NMI'_NM IIIII DEDICATED WATER RECYCLE SYSTEM ''um mug mei mot mil mi.u®um Eig ing pm u EN DISHWASHER MN NMI MEI INN NEI INN' NMI NMI IIINI NM NMI MN NUB® DRINKING FOUNTAINi®'1111111IM®ISI®'INN MINMN'MIL'111111,111111®'MN' FOOD DISPOSER NMEll'M'M"NMI M■MI N NEI MN NM NMI' !III.1 M 0 FLOOR/AREA DRAIN Mai®Min ini in®'iii MN ilii NMI NMMONMNMNEI INTERCEPTOR(INTERIOR) 1111111 MN NMI E;NM NMI NEI NMI MI N NM NM M NMI NM KITCHEN SINK NMI NM NM NMI MN I MIN NEI MI MI En NEI NMI NM NMI LAVATORY NMNM Nil-IIIN INK INN NMNM RE'INN MNEMNN ROOF DRAIN illi MEMENMUNMI NEI NMI MR EN MI ME NMI NM NM SHOWER STALLIIIII,NM 11111 MN NM'MN,NM En NMI NM IMO In'EN NM MI SERVICE/MOP SINK iii.NM iii.lini NMI MkMN Minli NM Mal ME MEI EMI MIN EMI TOILET ill.WM MN NMI EN M NM M NMI MN NM NNIN NEI MN EN URINAL MINE MIN NMI-'INN NM NMI NEI NE NMI NMI NMI NMI NE WASHING MACHINE CONNECTION MEI NM MINN INN MN M NE NS NMI ININI NM NE NU NMI WATER HEATER ALL TYPES in OENME liiii...MB Mii Elii NOM MIN iiii MENMN Eni WATER PIPING iMI®MN MR NMOMME al,NMMi.ii.MN OTHER EN®®®NNW= nuNENmmon MEI mon nimminummummi._ mit low®Nisi NE®---NEE Nor mil En NMI NM N INN NS MN EN IIIIIIII NE NMENN MR INN NM MN NM 111111111111111111111111111111111111111NINIIIININI1 MN MN,'ill-NE MN 1111111111111 EN NM EN i-. INSURANCE COVERAGE: i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO Q.) IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required�� g q ed by Chapter 142 of the • Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are t e 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 ci%lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _. PLUMBER'S NAME STEPHEN A.WINSLOW � _ILICENSE#,12298 SIG ATURE T MPD JPO CORPORATION O# 3281C PARTNERSHIP©# LLCO#MEI '''-- COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 J TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accounts•a able•efwinslow.com .......... --_ The Commonwealth of Massachusetts Pew Department of Industrial Accidents ;gj�= 1 Congress Street,Suite 100 _C1 Boston,MA 02114-2017 •,1-011=1 www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with 1.0 employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1.. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address:23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL, MA 02467 Policy#or Self-ins.Lic.#1821A Expiration Date:01/01/20./9 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the-Office-of Investigations of the DIA for insurance coverage verification. I do hereby certi , the ayhs and nalties o perjury that the information provided above is true and correct. Signature: 'Y Date: 1Z /31 f 1n Phone#:508-394-7778 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia