HomeMy WebLinkAboutBLDP-17-004692 •
E_; MASSACHIUSE T T S UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
.
k_____)
CI IY I,_ _ .. MA DATE 1 PERMIT T I P 17 --00 A
,_.... ___T. —
JOBSITE ADDRESS 2b 112/S d . D
OWNERS
cNAME CL)r -�?o,_ _ _1
• h Y �RDOWNER ADDRESS 1 , -, 'TEL S - L FAXIT______
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL U RESIDENTiALl/
PRINT •
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:Li PLANS SUBMITTED: YES L NOW
FIXTURES I- FLOOR-} BSM •1 2 3 1 4 5 6 7 I B 3 1 10 11 1 12 13 1 14
BATHTUB If—T(=I!----_AL_=1_`1`,II 1► t1 -(�=a --f I�_-_'l-_. _�-•-____ Gl
CROSS CONNECTION DEVICE �� .��T I �-
I L_.__- _i_-=-.�— 1r-...�_ F_--_ii-:--- ,f._.�I::3__..-v_511 1-----`I-_ I--—`Il„
DEDICATED SPECIAL WASTE SYSTEM 1C _ .`L -•-!�'"� '_' `I:,.......
il ..,_ Ii===- Il•_._ ..fL..=_ �i_ `.fit
DEDICATED GASIOiLiSAND SYSTEM _I—,q.-_ .;:11_._ _;�;1E_J 1...•_)P '![ I .-I[P j(�.i;ET T ___;'I.-.-_,.-.�1. �.
DEDICATED GREASE SYSTEM IL---I. . . il_.-_ . `�1 - _.11--- I_.•:.,-.lLL.._i[_�_ IlL-_-�'E •--JI----'(_r.l ll-- l�
DEDICATED•GRAY WATER SYSTEM 1L- �I......1r �.,r:.y��_—f�-_:, _, L ___ JI:_,=-J1 .—_a:..,_4`�1(.^ .'1----.1:-__.-:.£ET
DEDICATED WATER RECYCLE SYSTEM 11—_I=__._i i.._, ILL 11` iL.__--_ 1. ..:-:: L:--...,.!1-_-:ET_i.1I1 _31.-_=°II,-_-.::sL,,,-s l-
DISHWASHER - ilT - r
DRINKING FOUNTAIN 1=.11 -.71 II.7)1=E_-- -. 11 -:. I {Tr --11��1 ',1L-
FOOD DISPOSER I :I .- {[ _ _Y . -1I,- --s1_. r .-".._:.
'1 .- •1_ iI73[. . � .1
FLOOR i AREA DRAIN _ - `-_ _ 'rl -_ -
INTERCEPTOR(INTERIOR) IL 1 • i El ._ 1L_-.__E=1. _ �1. „ ;„,,._ _ [ 1.,3T1KITCHEN SINK �- - -s�_ __f _fr -� JI. f _
LAVATORY I_ - _
ROOF DRAIN L_ I1 !I . 1- 's-= I_., I1. .1 l --F
SHOWER STALL '� L=-��� ----•��r- -��,11-:_;__. . I.
SERVICE I MOP SINK 1 I 1.17-1 ' t 1 1 _ 11E
0 I 'TOILET • 1- �,1--._.._:I._. 'f.-1�._._'s._:._.�1_---`L_—_ __� i�l�r�1== `C.
URINAL _ _ .
- --- ice- :::: 1 :__' �� - --•�
WASHING MACHINE CONNECTION -
WATER HEATER ALL TYPES = ._ --
�,�_ a �,I-.:.:�� .._. .:1,_TIC--°'[:_ ..�I
- WATER PIPING 'I_.:__IL-- _ti1_ _'I._ __�,-1�:__,.,_il__ ,il:.__._.!I. _1�__�, __1.�-1'=� .•
OTHERi _ t
------- --------- - - '�.I.:..- - . .... --._. s f..�:C� ,[___a1=1 .1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142. YES 0 NO U
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
•
LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY U BOND U-••
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 DI AGENT
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 compll ce with ali Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. //
_ !LICENSE 12298 SIGNATURE ��a
PLUMBER'S NAME STEPHEN A.WINSLOW �' #
MPLI JP0 CORPORATION U#I3281C ;PARTNERSHIP #' .LLCU#L
•
COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE '�
CITY SOUTH YARMOUTH — STATE MA ZIP 02664 • TEL 1508-394-7778 f
FAX 1508-394-8256 1 CELL NiA . 1EMAIL accounisp gable@efwinslow.com — Lp 4
3
Li' �l uJJ e e-Ey Luar rssaagexaevree,v
wee ,i'= d . 600 Washington Street
Boston,!lam 02111
"a s� � www.vnass°gov/died
Workers' Compensation Insurance Affidavit:Eunlderes/ContTractorrs Jlectriu ans/P1umber_rs .
11p1p1icant Ilnforfmatiom! Please Print Le°lily
game(Business/organizationifndividual): ['C..tilU 1;-'3l Oft11 Q( ntfoviti . -ta- -csnq, Q?., Tell=
4ddress: r- a_e 6= :rrI
2ityIState/Zip: Sc ski"; zit--,ci : kPc Phone#: `20L=-3ct`-` 1'7 .
•
are you an employer?Cheek the appropriate box:' Type of project(required): •
I am a employer with '1 6 4. [ I am a general contractor and I 6. []New construction
' employees(full and/or part-time).* have hired the sub-contractors
❑I am a sole proprietor or partner- listed on the attached sheet.
7.-❑Remodeling
ship and have no employees These sub-contactors have 8. [Demolition -
working`for me in any capacity. workers'comp.insurance. g 0 Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required,] officers have exercised their 10.[Electrical repairs or additions
E. 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' 13.[Other •
comp.insurance required.]
ny applicant that checks box#I 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 anew affidavit indicating such.
mtractors that check this box must attached an additional sheet showing the name of the sub-contactors and their workers'comp,policy information.
an an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation. �r_.
surance Company Name: rra\.••.) tit o✓1 _ 1S1,vt:•t e.e . . sir 'v-'1
•
ilicy#or Self-ins.Lie.#: \$a. A - Expiration Date: c—1 Ol
b Site Address: 3 rnt�y 1/4 0--1 1 e OF,R 3416-jr tic; City/State/Zip: 0;-)4 6 .
Etach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
dlure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
ie 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 This
'up to$250.00 a da again Pt the violator. Be advised tbat a copy of this statement may be forwarded to the Office of '
vestigations f the DIA e
for insura e overage veri cay'ion. r
L_,/
to hereby certify unaG?r e pains ann.penalties a pe juty that the information provided above is true and correct.
•
ii
gnaturei - _ v'• 1 /I ,ram K Date: T��13 i 11 a°T i
v
. lone#: STA.,1T - I r 7X
Official use only. Do not write in this area,to be completed by ci;,or town oJjicial. . •
City or Town: Permit/License# •
Issuing Authority(circle one): .
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Pi_ur bing-Inspeetor
6.Other
Contact Person: ?home#: