HomeMy WebLinkAboutBLDP-18-001554 C_ MASSACHUSE F u S UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
V• CITY i_' .. G� 1----J + E 9 � 3 PERMIT;i I,1.I�O/�ao 1 /
IODSITEADDRESS �(JOWNERS NAME LOB j5-'�_►1 OWNERADDRESS 761c4-L.Iouf-H 10 ,L) ELF,j 77•07-T 1 ~ij
TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL Li ' RESIDENTIAL
PRiNT
CLEARLY NEW;le RENOVATION:Li REPLACEMENT:D PLANS SUBMITTED:YES NO
FIXTURES FLOOR- BSM •1 2 I 3 4 5 I 8 7 8 I 9 10 11 12 13 14
BATHTUB --. {II.__ (I 1 l ?�_._,Y -'--
CROSS CONNECTION DEVICE L- i•:Il__;;;�__i- AIL-- .. ----�a_ :III. __)I_:.. 1�.- -.'I_----=• __
DEDICATED SPECIAL WASTE SYSTEM I(_-=-._ :-( ;i� I _ ;( .r,i-__ II .-77.;[-_____ I •- .r t.l__•. ; _
DEDICATED GAS!OILISAND SYSTEM —
C, S __
[--���.---=-�.I�---.��I--- •._..�1...•_i�l__:.. yl�.... 111.�:�1.__ ti,-�-;:�-_---��II:.:: _ _ ice"•
DEDICATED GREASE SYSTEM 1` ;� # _ lI
�, I. �lll_==�IL_�--T.�==--�'- 4�—=t�--T-�---= -=III-----^I�---r-� '
DEDICATED'GRAY WATER SYSTEM 1=--I. I(. 1(_� .II_J __--=,'ill-___:-1 - III,._--_`IETrIi__ . i; ;l:.-_, •I
DEDICATED WATER RECYCLE SYSTEM �__,I_`- `: '3 ,
DISHWASHER ( 'I - - `—` - � .
�_��,_ ...:II. _. "li, ��I_.�-',b_-�-'-•. ill. __ �I 11_:.:>_ _ �I,._ al...-.-�.IL !.
-- ._ "�.I ill_.:__� - -�I�-._.I . _.
DRINKING FOUNTAIN 1---` I `�I - . . .( . •--- ' : ,, -^
FOOD DISPOSER 1 "; �-"
FLOOR iAREADRAIN Ir.1=- ( _ [4- =-- -1 7_-. :-_._-_1I::. ' ,• )I_ i , - .7I
INTERCEPTOR(INTERIOR) 1- - :..1 is ' . _fir- - :-_-:. -. '_ ,1 . I[ . . . -
=
KITCHEN SINK 1 — I_.. 1- =[ _ ,[I . •_I .~ I 4 , 17•. _- II_____.-.
LAVATORY -I—_ - I _ . i i.--
ROOF DRAIN , ET [.. i - E -.. . r ?ET __ l .._.
SHOWER STALL -
`
. _ - —�
_ __ _
SERVICE iMOPSINK I 9 i -11. IL 1 V 1
TOILET II i L_ •_ --- 1_.12=1: ._ ___! -_
--_----URINAL: ,r- � T ® IF 11_ I _ — =MNWASHING MACHINE CONNECTION ( —
WATERHEATER ALL TYPES _,� ' — €
- WATER PIPING _` �1�- i I it - 'I: -- ,
0 ER�_._... ... _��. -.:. — � --r
J! 'wit.�i ir : ;1 7.1
_
— — —._ ..:__s:__._: . —
INSURANCE COVERAGE:• _r
I have a currentliability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142, YES f NO
`
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOXBELOiIT -
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND a•• (i
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not havethe 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 U AGENT ]''
SIGNATURE OF OWNER OR AGENT
I hereby oertifythatall of the details and information I have submitted or entered regarding this application are, 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 corn;lance with ell Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws, i
PLUMBER'S NAME STEPHEN A.WINSLOW • " - - 'S �/��" J
LICENSE 1.12298 i SI 1 RE LP I)'
MP Li JP Li CORPORATIONU#3281C iPARTNERSHIPU#[LLCIDE
COMPANY NAME EF WINSLOW PLUMe1NG S HEATING i ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE
MA ' ZIP D?664 1 TEL 1 508-39¢7776
FAX i -394-8256 1 CELL NIA . !EMAIL accounis a able@n enyinslow.com _� ti
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qiii„,_Ey migpmogeteu no
'�= d 600 Wesshi:sto sgtis Street
f BOMB,Ml; 02111 .
'a - PA miss govfdio •
Wcntkers9 lCouperlsation Insurance Afdavit:]uil�ders/Cflojcttrilctcrs/ 1Qctrrjcians/Pl ubcrs ,
1p�sticant mMormatiO]a PeaselPrr .tLegibly
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game(3usiness/OrganizaiionlIndiyidnal): �•'�",tt(vitcrvi�tf°� �{�'�.t�i�'tc; <_• 4;l�CiY1ul=t, `-4.�.1 (�`c�:
. . 0 L. r .
!address: Ei wl..vl i
�,trft
city/StateIZi : ,-c f `e --ejfin ;'>,< Phone+: � .' h 3`11_11`Cs . -
it a you an employer?Check the appropriate box:' Type of pro ject(required):
`' I am.a employer with `t 0 4. I am a general contractor and
6. ❑New construc�ilon
employees(full and/or par-time).* have hired the sub-contractors
LI I am a sole proprietor or per Liar- listed on.the attached sheet,= 7. El Remodeling
ship andhave no employees These sub-contactors have . 8. []Demolition
workingforms in.any cap acily. workers'comp.insurance, 9. 0 Building addition
[No workers'comp.insurance 5. C.We are a corporation and is
10.El Blectical repairs or additions
required] officers have exercisedtheir
E.I am a homeowner doing all work .right of exempuoriper MGL 11,0 Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),andwe have no 12,El Roof repairs
insurance required]t' employees,[No workers' 13.E Other
comp.insurance required,]
ny applicant that checks box#I must also fill out the section below showingtbeir workers'compensation policy information, •
iomeowners who submit this affidavit indicating they are doing all work and then hire anode contractors must submit anew affidavit indicating such.
)ntractors that check this box must attached an additional sheet showing the name of the sub-contactors and their workers'comp,policy information.
on an employer tiedis providing workers'compensation insurance forray employees. Below is the policy and site
formation. ,
{ p •surance Company Name; 111,11,,,...0 'i c t � ['vti _0'1iv,, ,,,
ilicy#or Self-ins.Lie.##: 1 { A - Expiration Date: c--1 .Tot
•
b Site Address:: 3 .nr;rw:to�.ti cx� �v', , r'j iY . k 1 Cityy/State/Zip: t -i fn 7 •
Rath a copy of the workers'conjiensation policy declaration page(showing the policy?nanober and expiration date),
dime to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
is up to$1,500.00 and/or one-year_•imprisoiunent,as well as civil penalties in.the form of a STOP WORK ORDER and a fine
'up to$250.00 a day a ainetthe violator, Be advised that a copy of this statement may befoxwardedto the Office of '
vestgatiions f theldfox insuranegl.overagaveri ayion, • f
If /
to hereby certify u.likt.tke pains urd penaltle'o pe jury that the information provided above is true and correct. •
gna re;..� y• i! ,?�* Date: 4 L�t, I I/`.o 4 .,
ryy u
. ions#: iddn•IS 1-)9 7g .
Official use only.Do not write iii this area,to be completed by cry or town official . .
City or Town: Permit/License T
Issuing Authority(circle one):
1:Board of Health 1 Railing Department 3,City/Town Clark 4.Meet-Leal Lisp actor 5,Plumbing•I'rispecto_
6.Other
contact Person: Phone ri: