HomeMy WebLinkAboutBLDP-18-007030 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�cv'��- CITY UL� T _I MA DATE ff 15-_ PERMIT# . lP-lr3TOp
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JOBSITE ADDRESS l"� 7�i1�„iZ sr 1 OWNER'S NAME AZ'f G� Z,
OWNER ADDRESS L , ./ /.C.)h 2,... ? TEL C :gaa'.3`�FAX 1 --
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TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL 1 ,I RESIDENTIAL W
PRINT .
CLEARLY NEW:i- I RENOVATION:1 REPLACEMENT 1V PLANS SUBMITTED: YES - NO1✓
FIXTURES 7 FLOOR—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB r,,.__,:I I 11 I: I ! I I I II
CROSS CONNECTION DEVICE lw I ] ' ,I ! l I I
DEDICATED SPECIAL WASTE SYSTEM �._..,l ;I I I- i. I _ 1
l I 1 I '•I
DEDICATED GAS/OIL/SAND SYSTEM I
DEDICATED GREASE SYSTEM I _ ,,,,, - I
DEDICATED GRAY WATER SYSTEM f ,1 'I .. !I I I
DEDICATED WATER RECYCLE SYSTEM I II_.. I :I
DISHWASHER I w;
l - I I I _ I ! II '1
DRINKING FOUNTAIN �.. .. : I I
FOOD DISPOSER I L I
FLOOR/AREA DRAIN I I I I I I 1
INTERCEPTOR(INTERIOR) I I 'I I I l I �R
KITCHEN SINK I
I
LAVATORY
ROOF DRAIN --
SHOWER SHOWER STALL I 1 !
SERVICE/MOP SINK [____, I 1 I
TOILET 1 i1 II l
URINAL 1 ---,I I I l _ . If "II 1 I i
_WASHING MACHINE CONNECTION 1 _ _'I I it ' I_ I1 I�. � i I ! � 'I
WATER HEATER ALL TYPES If 'I I `'I i_t 'II III - �'I
WATER PIPING—,__--_ ---_ W _ -_ __ I ,I iscl
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OTHER I
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES i'I NO I„t:l
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY[i ! OTHER TYPE OF INDEMNITY 1 BOND I,,,
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the S)
Massachusetts General Laws,and that my signature on this permit application waives this requirement. 1
CHECK ONE ONLY: OWNER I - 1 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 tru 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 comp'ance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4
PLUMBER'S NAME I STEPHEN A.WINSLOW LICENSE# 12298 LL SIGNATURE
MP ✓ JP ) CORPORATION L #-3281C 1 'PARTNERSHIPL#L �_ ILLCI_ �'.#
COMPANY NAME;,EF WINSLOW PLUMBING&HEATING ]ADDRESS'8 REARDON CIRCLE I
CITY SOUTH YARMOUTH J STATE r MA I ZIP 02664 1 TEL 508 394-7778
1 EMAIL E accountspayable@efwinslow.com
508 394 8256 1 CELL NIA -__-
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Department of Industrial Accidents
"fit= l Office of Investigations
G -"�1- �e 600 Washington Street
"t0�— Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Legibly
Name(Business/Organization/Individual): ., • ts'1 1 C u� k'jo rIc tl•_ n'o), _ I en.
Address: �.- "
City/State/Zip: Sc.,:-'do ° or v-4,1,141 tikA. Phone#: S 1•-1 T7S
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
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. 1 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. ❑ Building addition
❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
❑ 1 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 ❑ Other
thy applicant that checks box#1 must also till 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.
isurance Company Name: y--rc,,,,d;, c-k,..I k c.-,' k
olicy#or Self-ins.Lic.#: 1 Di
Expiration Date: ‘-1 - ;-)01
)b Site Address:,?. arvv-kcv-1 ' e..kII\ .A,,,,,.e., , Q1' FCity/State/Zip: O.) I
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 against the violator. Be advised tljat a copy of this statement may be forwarded to the Office of
tvestigations�Ofthe DIA for insurapeeoverage verif' ation.
do hereby certify under ze pains and penalties o. pie/jury that the information provided above is true and correct.
mature ,- Lm
it.1'A Date: i` . 7 i - ,lad
hone#: ` tg -35'i - 17 7X
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#: