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Home My WebLink AboutBLDP-19-005144 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i. el p '_ ` %WI � CITY _V(1 Limn `/ .h_c MA DATE ; / I" PERMIT#/' 7�P 5 JOBSITE ADDRESS I__LB_._rec1 qr , __..,_____,_.1 OWNER'S NAMEtr 1.0.CP_he 4 I OWNER ADDRESS lA EI: Stel.S1..�__(OL..t_C K( -1i: __ 3(JFAXI .... p ' _ � �� ) _��L�c TEL x.. _C TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL D PRINT : YES 0 NO[1]CLEARLY NEW:� RENOVATION:El REPLACEMENT. PLANS SUBMITTED FIXTURES Z FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 I BATHTUB I I 11- , CROSS CONNECTION DEVICE l DEDICATED SPECIAL WASTE SYSTEM 1 DEDICATED GASIOILISAND SYSTEM Ui U lc) DEDICATED GREASE SYSTEM r 1 DEDICATED GRAY WATER SYSTEM U DEDICATED WATER RECYCLE SYSTEM - f II U DISHWASHER _ I SI u �� 1111111 ^ DRINKING FOUNTAIN -- I) I FOOD DISPOSER FLOOR 1 AREA DRAIN I INTERCEPTOR(INTERIOR) I I 1 l 11111111 KITCHEN SINK __--- LAVATORY _ 1E1 MIMI__mt.- ROOF DRAIN IIIIII MINIM - ---- SHOWER STALL i ® _ -- '' . SERVICE 1 MOP SINKIIIITOILETOff jairillili mmi URINAL WASHING MACHINE CONNECTION 1 WATER HEATER ALL TYPES 1 - WATER PIPING OTHER-L 'r lr pi.p. _ __ ____ gimunw, ....INN up � requirements- __._ � ~^ INSURANCE COVERAGE: / l,�`-' I have a current liability insurance policy or its substantial equivalent which meets theq nts of MGL Ch.142. YES El 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 0 t 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. a— 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 true d 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 comp!' e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE MpID JP© CORPORATION # 3281C PARTNERSHIP#J ,LLCO#) I COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLET_ ___ T __ ________-_.-______I CITY SOUTH YARMOUTH STATE _ MA_ ZIP(02664_ _ _._ I TELL 508`394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com _ _ _ __ . . , __ _ _._ .______.._. __._Tv 2 , 43, h� .21%1/4 a'66. 4_+L II 66Y C 6C/D 6 VY6.6i..a. J 1>16b.D.D666.C b a....bbu m� Department of Industrial Accidents ft i Office of Investigations =°°f� 600 Washington Street "' Boston,MA 02111 , _.— r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers kpplicant Information Please Print Legibly J vame(Business/Organization/Individual): E.c.W, s i o,j Ov,,,,\b kivj 1 ' \.ddress: Y.. (Z.ecdw, Cst rc,t e_ iity/State/Zip: Sou Vcrr„c,,,i-t.- Or Phone#: 53b- 394-7 ? 1 re 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. 9. El Building addition p We area corporation and its required.] officers have exercised their 10.[ Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.❑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.❑ Other y applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'tractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. n an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site mation. t trance Company Name: �„s CAQ: do k J'G eI (del VI'l cy#or Self ins.Lie.#: I$01 I AExpiration Date: t—H — aOl9 Site Address:a3 `clnnr+xv).,,ea.t I CI^es Wt1 City/State/Zip: O,)'-1(0 7 ich a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 p to$250.00 a day a:ainst the violator. Be advised t at a copy of this statement may be forwarded to the Office of ;stigations . the DIA for insura •- overage veri ..j on. hereby certify un e e ains a penalties o jug that the information provided above is true and correct. atuT : Date: 1a i am le#: cb% 35y- 7 77Z Wick!use only. Do not write in this area,to be completed by city or town official. ` 'ity or Town: Permit/License# ;suing Authority(circle one): Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Other 'ontact Person: Phone#: