No preview available
HomeMy WebLinkAboutBLDP-17-000293 \w, ; 1ZN MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK fi e. 5I-6yy CITY 1 <-+ i ,")'I/»rip 1 MA DATE _ PERMIT# P-17-061.)01"?' JOBSITE ADDRESS //,, (l/i/;k14/1,l /.7Irx ; OWNER'S NAME} /2/JZkJ,_ I NJ OWNER ADDRESS J TEL 217 ,`j5''•.r jFAX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ID RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:1_ PLANS SUBMITTED: YES L NOLI s'\ FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB . I7.7. c7J'LiTI _ -I (- d1�11. . _ci 1- ._ . ris CROSS CONNECTION DEVICE EMI __ { , . , I ._1E7 I - .1[ ( f_^ f IImo DEDICATED SPECIAL WASTE SYSTEM i .k [ I _ J-l—.r, 1—. I I.. J � S..,_ .. .-�_ T ,.... b DEDICATED.GREASE SYSTEM M 'I--_ I, e,-.9a.v.,fit,,.. SL -(_,_..1 I_ _II._ 7 . 7r. LDEDICATED'GRAY WATER SYSTEM IMl .. ; .-F [7-1�_.--.,,, _. i . lil 'L. , FT)[ tli1, .{1 DEDICATED WATER RECYCLE SYSTEM' , i E y(I[,_„�,.,�IE-- I i I :.![ [-, !I J I _11 rE-1___ ;,1------, DISHWASHER • Lil ii: I _ JL i I 'r �... I ai DRINKING FOUNTAIN .L I,_ :_, I� I711_ - kr-'1 1T-(`.,r.. 1- -1 '[,��_z-i FOOD DISPOSER [--'I I-1 _ E. I I . _i'r.-1 1- FLOOR/AREA DRAIN L L�� lit_._ ._ . . _ I�, i ,1- tr _ _ __-ram. INTERCEPTOR(INTERIOR ,___,IL._,...IF--L- z.`'1 . .I1. - ',(.-.71 .177 l it 1(7 .;. _ z-n f KITCHEN SINK I _. ;I -;I '.I.. 1[ 11 Y . _'1 .`;I y 1--- `i _ ..' 1 LAVATORY E ii[ .11 :C 7,1 7i _ ,il 41 ';1 ,1-- . '1� 'r --' _-`[— , 1 I—.1- ;r . ROOF DRAIN ,I -;(- 1. . i.... _-11.-.��L �.-. I_ .,:;� _�_ _. SHOWER STALL , Jfi I ,I- EJ. ill �� I[- . _ 1...._. _ �[_ SERVICE/MOP SINK . I LI.�r-� .. i�,., .�I7-' i r.... �—'1,... . -..,.1 L [- TOILET ,.�.._ 'I-- , . !- �_. 11 I.___„d�_(-_f_ 1 . . ' .+ URINAL E. I I. ;[— TI _,.._1 ,(--!F. 1 - m�l>F>..., WASHING MACHINE CONNECTION 'MI-- 'L 1 �. ..,..:,.vim-1 '11 I ,'' :f -7( !1 —;'.1. . _ _ __ WATER HEATER ALL TYPES _ I _ _ .'1_ _::I_ .�?I . J .. . }{-_,.,�11 y,. . ._�r ,� 1 ___` .-. WATER PIPING . . 1—r-iP i.r - t[--[ _1 ?F.-1 .. I k1--_: OTHER 1 ( r� I . ,.. I+ — _ � �1 ;. 'r l LITE-1- I 'I-_ -i. '�_ . r_ �.A.._..___„___ Y _ f 'f I :1 ram. I . [ .. :1 ..I :1 J ,L Li` ice, E,:4._ Imo` . _:1 Ls_.:i INSURANCE COVERAGE: I have a currert liability insurance policy or its substantial equivalentwhich meets the requirements of MGL Ch.142. YES Ed NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND E9 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 LI SIGNATURE OF OWNER OR AGENT I hereby certify 1hat all of the details and information I have submitted or entered regarding this application are true 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 compll ' e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ( p,-t--) 4ZL..� i-‘61 PLUMBER'S NAME STEPHENA._WINSLOW _ _`_LICENSE# 12298 i SIGNATURE MPLI JP: CORPORATIONS# 3281C IPARTNERSHIPL#L LLCLI# COMPANY NAME EF WINSLOW PLUMBING&HEATING ..ap ADDRESS 8 REARDON CIRCLE ,� q l CITY SOUTH YARMOUTH 1STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394. 6 CELL I NIA 1 EMAIL accounlspayable@efwinslow,com r 6 = i_^� UJJice of Investigations t_-.� 600 Washington Street ---r- Boston,il'L4 02111 ����" '" Www.massgov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information t^ , ) t n I� `` Please Print Legibly valve(Business/Organizati on/lndividual)'E.c.W t t,$[0 W 00,,,to wtc .�vl to h . �e,I✓1�. Address: Q.?orittcn CAirle- :-..'ity/State/Zip: So kv\ YLrw,c3...Ai t i`kPr Phone#: '50S-399.-1''7C1 ire you an employer?Check the appropriate box: " am a employer with '70 4. El am a general contractor and I Type of project(required): Ail employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 0 I am a sole proprietor or partner- listed on the attached sheet.1 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. [No workers'comp.insurance 5. CI We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10.0 Electrical repairs or additions ❑I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.0 Other ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such mt actors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp•policy information. in/an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site formation. surance Company Name: Ayyp,,,.$ rkol-tnz-A fL&el r v-vi .licy#or Self-ins.Lic.#: {5 a I , Expiration Date: {—I- a(�l'7 b Site Address:a3 newt..p-er-1i-b Aiu,kJ CC.Zg it City/State/Zip: 00W✓'7 Rath a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). rilure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a 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 daynst the violator. Be advised t[tat a copy of this statement may be forwarded to the Office of vestigat ons Sf the DIA for insurap overage venal-{ y ai on. io hereby certify not, XI:an penalties o p jury that the information provided above is true and correct. gnat4• Date: l a,31)aRO i 0' lone#: STA•354-777x • 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#: