HomeMy WebLinkAboutBLDP-17-005940 MASSA CHMSET d S UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBIiNG WORK
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I MA DATELO5i r/ 71 PERMIT r/✓GD/'`-/7-a,,y 'Vti
JOBSITE ADDRESS _4 ^ • OWNER'S NAME ( __ ___ I.a __
fp OWNER ADDRESS r - u. . I TEL 17- Q59 FAX ____;
TYPE OR OCCUPANCY TYPE COMMERCIAL 11 EDUCATIONAL U • RESIDENTIAL"
PRINT •
CLEARLY Y NEW:U RENOVATION: ' REPLACEMENT:0"-- PLANS SUBMITTED:YES u N0w
FIXTURES 1 FLOOR-) BSM 1 •1 2 I 3 4 5 6 7 I 8 s T 10 11 12 13 liti
BATHTUB If -(!-- ,i „1:_, C':-=1=IC ..:EI__.� 3.11_- :L__...S
CROSS CONNECTION DEVICE 11_. ':Il:=_. _i kT.:.._)1I_,..., I_.._._,i.- _11_--__I._ -'I i(:;
DEDICATED SPECIAL WASTE SYSTEM IC...sl.._.,:- _ ETI__. _1i__l__TII� .i�___ 1(__.._ I —__I
DEDICATED GASIOiUSAND SYSTEM [_ `I -___ , 7 ,:�r_1...•_ ._1 71(— ,11_ -.I:
DEDICATED GREASE SYSTEM .:
INNIIIk MUM
DEDICATED GRAY WATERSYSTEM L I.._.. t fl__.r_11= JII. _I_--`L,.._ ; �(.: -.lil. l,-__.-�.ED
DEDICATED WATER RECYCLE SYSTEM -LTD 1 i "-a i . " 11
DISHWASHER • i=�i.L - _-_,1--==--p-_:,_._
DRINKING FOUNTAIN
L,... . iE_ IL. T.-z- �11_-_}.-gip.:-.:s.-__,r,_.J_ . nl_,.--_ i ..; II�._:- .__i.. C�
DRIN NGFOUN I ,EJI. I ?f- -'II - �—JIB I. II `��®W� 0.
FLOOR I AREA DRAIN 1L.--11:--._-rl ___- ."
INTERCEPTOR(INTERIOR) 11.—:._1( y
KITCHEN SINK l- 1->, t M
. LAVATORY I__ -I ,_-_'®� ®a'j�® - -
ROOF DRAIN I,--3
SHOWER STALL IL- 7 M®
SERVICE I MOP SINK 1=1= __AIL t;.-_-;IL—I_-_- L__s_-_,SI.-=.-.-=_ I_..=:_ -.F
TOILET 1---- i I:_ 11=-- ( ._..-I- =-3—__ I_ t O
URINAL --i[ [1 .. .__.)1____-. ;IL—i
WASHING MACHINE CONNECTION ®1 _::__:1. _'f= `11:--- II . :_. . _IIIIMENTI_
WATER HEATER ALL TYPES 11___=a®1__--:.`IL-.-..-®P _....,_-I,.__.=_i1._ i�:.-_.-
- WATER PIPING _ � �i��®®®®
OTHER . *7ch 44°. - Vw1< 1-__IIi$gRRgiPR
1a---- .-___...__.._.... :.--..-.LL_.._-.r _
INSURANCE COVERAGE:
' I have a currentliability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142. YES 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
J
UABIUTY INSURANCE POUCYE. OTHER TYPE OF INDEMNITY- BOND D--•
Cr
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the CIS
Massachusetts General Laws,and that my signature on this permit application waives this requirement, i
I\
CHECK ONE ONLY:• OWNER U AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application aretru nd 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 nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHENA.WINSLOWt
+LiCENSE 12298 '-
SIGNATURE
MP El JPU CORPORATIONri# 3289C PARTNERSHIP[#1 1LLCD# • A
E •
COMPANY NAME� F
WINSLOW PLUMBING&HEAI INN ADDRESS 8 REARDON CiP,CLE w_ �V�
CITY SOUTH YARMOUTH 1 STATE ZIP 02664 1 TEL 1 508 394 7778
. .
FAX_508_394-8156._CELL[NIA EMAILoispaccunaya �bleenvmsow.com . J
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17 '
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�'�-} 600 Washington Street
Boston VA 02111
a .. Washington
vaw'wv .mass.gov/dsol
-' Worker ° Conipensat or I_Insutralnee Afrl.dnvnt:Boulders/Confractors/IHleetridans/Plu hers .
1i&lleant nformatiorn _ Please Flint Legibly
. ir i
game(Business/Organization/Individual): E.LC,ttikl 1sr61 OW lt<;t sd;,;io( a. 0-ZL- Sul. cs. i'it•
�
N.ddress: 51` ,C' cr= c,,c1
. . ... . • .
��i ty/Biota/Zip: o s k �^�c VA
' Phone#: `.,E3 ~314-`'03
sr you an employer?Check the appropriate box:' Type of project(required): •
•I am a employer with '7O 4. ❑I am a general contractor anal 6. 0 New construction
employees(full and/or part-time).* have hired the sub-contractors
El lam a sole propri�nrpar„et- listed on tile aftaahed sheet._ 7•'0Remodeling
ship and have no employees These sub-contactors have - 8. U Demolition -
working`for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp.insurance S. El We are a corporation audits
required.] officers have exercised.their 10.0 Electrical repairs or additions
El I am a homeowner doing all work .right of exemption per MGL 11.1]Plumbing repairs or additions
myself.No workers'comp. • c.152,§1(4),anciwe have no 12.[]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.
Dntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
tat an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation. l • �`'�
surance Company Name: P1'h� tA'0k0u-A . 1�,,pci\rck r1 e'Uv\, .�1`-fi
:Roy#or Self-ins.Lic.#: \'D..1 PT - Expiration Date: —1" atyt
�� r�,rn k_ �J 1 ,° C x°k ' 1fl r 7 .
b SiteAddress:a3 �' 1 � � , �-��ttiv'I City/State/Zip: �r�-#G:t,J
t
ttach a copy of the workers'comliensation policy declaration page(showing the policy number and expiration date).
diure 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 imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
'up to$250.00 a da a ainstthe violator. Be advised tbiat a copy of this statement may be forwarded to the Office of '
vesfga`uons the DIA for insurareeoverage veri,'c-anon. • t
I I
la hereby certify u- e . e pains an.. o p penalties eljury that the information provided above is true and correct. •
gnatut`r . % Date: (a l 3 i i a016
. lone#: SfYl•39' r`L' 7X •
Official use only. Do not write in this area,to be completed by ally or town official. . -
City or Town: Permit/License# •
Issuing Authority(circle one):
1.Board of Health 2.Building 3.City/Town Clerk 4.Electrical Inspector 5.P'lumbingInspector
6.Other
Contact Person: . • Phone t: