HomeMy WebLinkAboutBldp-19-000621 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Gl= CITY Yl l(COI14i 1 Ad/4- L.Y4I'lflDUhiI MA DATE 112t/ I' PERMIT# /94-0—R-116°6a
JOBSITE ADDRESS 1 podsoliate Poir4 OWNER'S NAME limo{hN Wa I /- 1
P OWNER ADDRESS61en�Al e Avg Sn P,r✓► II TEL Str636a394)6 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL El RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NOO
FIXTURES 7 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/OWSAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM II 1
DISHWASHER Y _,___._.
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
MI -
ROOF DRAIN
SHOWER
SERVICE MOPLSINK CIMIIIIIIIIHERIMMIMEE
TOILET NMMEINMMI Mill Mil®ME EMI Mil MI® NMI
URINAL _ ®
WASHING MACHINE CONNECTION III IM
WATER HEATER ALL TYPES IIMMEIMEN
_
WATER PIPING III
OTHER EREill1. ®NM NM Ili.MN
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
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 El
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
L ) Massachusetts General Laws,and that my signature on this permit application waives this requirement.
-C.LP 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 ar: rue 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 c; pliance with all Pertinent provision of the
�D Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
tr
PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 "' SIGNATURE
MPEI JP® CORPORATIONO# 3281C PARTNERSHIP®# LLCO#r •
ier 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 accountspaxable@efwinslow.com
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10L6 6iV0/L0011,4,0L rY bKLL/L VJ LId KJir.L../L KO 6.6L,7
Department of Industrial Accidents
' Office of Investigations
= 600 Washington Street
Boston,MA 02111
moo'" www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information cc Please Print Legibly
L
Name(Business/Organization/Individual): 't-• 'As L O;,v eloa,.46 kiic L tta-n C'e) i,n(
Address: Y. (4ef an rck
City/State/Zip: Sc,s Ycr-,m0Jin r{P• Phone#: 50S- 399-1 V S1
Are you an employer?Check the appropriate box: Type of project(required):
I 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
ID I am a sole proprietor or partner- listed on the attached sheet.t ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
❑ I am a homeowner doing all work right of exemption per MGL 11.111 Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.0 Other,
thy 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.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation.
tsurance Company Name: ws CA kl CA k f Ora el(
olicy#or Self-ins.Lich!.^'#: '.3 a I A Expiration Date: (—I - aci�.)
)1)Site Address: 3 Crwv‘efl Au-e1 CGe3k i4 I (1 City/State/Zip: O )'4(a?
ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ailure 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 a ainst the violator. Be advised t. t a copy of this statement may be forwarded to the Office of
ivestigations • the DIA'for insura overage verif a on.
do hereby certify un e e ains a penalties o p jury that the information provided above is true and correct.
ignatuT :
Date: .a) 3 t ) a•17
hone#: Sb 35'1. 7 ng
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#: