HomeMy WebLinkAboutBldp-17-005632 MASS II USETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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--::;4_-E.- CITY MA DATE' PERMIT# _/7 003-63 .
JOBSITE ADDRESS / [ C I OWNER'S NAME t
+
J) OWNER ADDRESS TEL.77 Li. Ram FAX i
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:D RENOVATION:® REPLACEMENT:Eg„/V PLANS SUBMITTED: YES D NO®,---"---
FIXTURES 1. FLOOR--+ BSM •1 2 3 4 5 6 00 9 10 immEumn 14
BATHTUB ,0 _. LMM__ l _I, !� I,- .0
CROSS CONNECTION DEVICE M _ 1 'Im r --_ _:
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DEDICATED SPECIAL WASTE SYSTEM 1� Iq_ r __ ,
DEDICATED GAS/OIL/SAND DEDICATED GREASE SYSTEMSTEMi - I� '� II !!— 'I
al iJ m _ +
DEDICATED'GRAY WATER SYSTEM AM _ .; i a� ,Pt.11iMilitiliVMMI
DEDICATED WATER RECYCLE _SYSTEM Irl jlji. ( j , .
DISHWASHER �� + ��;J .�i�1Jl,�` _- -:
DRINKING FOUNTAIN !:T[iI . J*MjT:pj : i; ,.. :, __
INTERCEPTOR(INTERIOR) II ._..:1, T
KITCHEN SINK . ••1_ ; ,
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LAVATORY
ROOF DRAIN LPN _ 1111011111 . .
SHOWER STALL W' ._ mill --..
SERVICE 1 MOP SINK iii_ �_ _ JI�l_ "
URINALTOILET I m t
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WASHING MACHINE CONNECTION II I 111111,1011101111111111_ I .lL
WATER HEATER ALL TYPES ; _ ; �> IMIIIIIIIINI _ ..
WATER PIPING
OTHER ailliZIWROZImmin'"
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY j OTHER TYPE OF INDEMNITY® 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.
CHECK ONE ONLY: OWNER ® 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 true an ccurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In complian with all Pertinen�siohe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 1229$ _1 SIGNATURE '
MPIJ JPU CORPORATIONU# 3281C i PARTNERSHI P ED# LLCI:1#1111111111 •
COMPANY NAME EF WINSLOW PLUMBING&HEATING i ADDRESS 8 REARDON CIRCLE
CITY SOUTHYARMOUTH I�STATE MA ZIP 02664 TEL 508-394-7778
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FAX 508-394-8256 (CELL NIA EMAIL kcountspayablena,efwinslow.com
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Department of Industrial Aicctaenrs
p'_=,ii��/ Office of Investigations
_: _-y Washington Street
?I:1= Boston,MA 02111
<:,crYuf• www mass gov/dia •
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly •
Name(Business/Organization/Individual): e,e•W•✓r510v3 Q(V.,..c0 m6. L O t.0.�l c � l el(.
Address: �P � I L'- . (� -
City/State/Zip: SO.s l(h Y.r.Ic,,.k 1`MP Phone#: ` 0S- 3ct`I-17?S
Are you an employer?Check the appropriate box: Type of project(required):
XI am a employer with 70 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors'.0 I am a sole proprietor or partner- listed on the attached sheet.$ 7. El Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working-for me in any capacity. __ __ workers'comp.insurance. 9. 0 Building addition _
[No workers'comp. 5. LiWe are a corporation and its
insuranceofficers have exercised their 10.0 Electrical repairs or additions
required.] airs or additions
❑ I ama homeowner doing all work 11.right of exemption per MGL ❑Plumbing repairs
myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
1ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
elm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Formation. //�� �� CAOjs el� n
tstrrance Company Name: �iYYD:� 1'tJ \ vcv
olicy#or Self-ins.Lic.#: `$.I Ac Expiration Date: ("l — adll
)b Site Address: 3 c/i vi'ea•-111-1 �I CtAes tT VI City/State/Zip: (5.1 Li b 7
.ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). .
allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
ne 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
f up to$250.00 a da ainst the violator. Be advised •••:t a copy of this statement may be forwarded to the Office of
•
, tvestigations the DIA for insurapeeloverage veri ; on. i
do hereby certify u e ains an (penalties o p• 'ury that the information provided above is true and correct.
i attt-e;-.._.__ a "" Date: d DI 3 II aO 1✓(
hone#: .c0 • 114- 7 77X
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.Electrical Inspector 5.Plumbing Inspector
6.Other •
Contact Person: Phone#: