HomeMy WebLinkAboutBLDP-18-000173 •
;_, MASSACHIUSET T S UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
" _s CiTY �, MA DATE-iriEZ PERMIT-1'i. ,'. DP-Ig Le /7
11 IJOBSITEADDRESS ° � OWNER'S YYni _
p OWNERADDRESS uw TEL[ '••- a sl� 1
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL 13
PRINT
CLEARLY NEW:D RENOVATION:LI REPLACEMENT: PLANS SUBMITTED:YES Now
FIXTURES T FLOOR-+ BSM •1 1 2 I 3 4 5 6 7 B 3 i6 'H 112 13 14
BATHTUB -_._-L_—ill--:.:L-_-_`•LT sll------II-.:,.,1ya". 11 IL_.�__.tl__:SB_ l- s
CROSS CONNECTION DEVICE 1-11:_.:. 1IrTII II-.•:__slf:- —•IN_.:--- III-:_._ i S t -- _i
DEDICATED SPECIAL WASTE SYSTEM 11--=-1 �,i1-_ .'Ir.:.;Ca.
IE°r=• --,-'1L, :slit-('- ,li IL_.,II_--•_R:_-._.1l_=-r
DEDICATED GAS OiLISAND SYS-I EM 1 ;T_`I._ ;C ... - 1_- l,.•- f l-" {,
DEDICATED GREASE SYSTEM III�Y- -•II-4 �L__^_ i Y t �� 'l._._::�1-_:��I,_.��I� .-:�L:-.._ .'r_.-.
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- �- ;I. �� :+►•--=_=III=�,.•:3__ =�1_==--�L__fG=rill ���•.- -s1--.;.�U:=--•=`1--�--`
DEDICATED GRAY WATER SYSTEM �'1.•�1�' -_'-( #`-";' �� � � � i
If•.,�.._�:.-ai=_�=-'li_�.��,�:-,=. I�_.=.--=1a1=..: ��T____.If-::..i�l._`�I:.:_,-:�.
DEDICATED WATER RECYCLE SYSTEM =_111 ...II_ IT __ -:I T?I� _ ••
iO^ DISHWASHER • II_=--.'II III. _ 11 - - ,I-_-_-L. _ _ _ .I_ r - 1.
t ) DRINKING FOUNTAIN C�`P . 1r-1_._-_.�L,.:_-=1.=_�_ i-1:.: ;rrl'. .-?II:>: •1I •---'.(. ;
._ —- • ..,_
-' - FOOD DISPOSER I—fIL _:1-< -_= - -11:-...-- M[-.1. i - r m 'll =
FLOOR i AREA DRAIN `-J`L"=L:: - _ _. _
+ INTERCEPTOR(INTERIOR) - _'Fi1 E_TT[ 11::.t-t1 E-.—.;1. __ I .- __:,_I _ _ - •:ITI
KITCHEN SINK
LAVATORY 1_,C- ,1-_:__ ''[-- -'l._ ;ill-.._. II_. -_-11--:--_:11._ =:1__:_-=C�_ ,1-. i _-,_-:1.— f •
ROOF DRAIN PJI .:1 .-..' ' - =- — �= _.
SHOWER STALL II— : =: -_ --.
:
SERVICE/MOP SINK I -' - - -' -- __- -- '-
A1�
TOILET :---_ -,_ _...-.._ -_= -___ --:---
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URINAL ........, • _ ,fir 1 . �1 p i
5 GMACHINECONNECTION r�•.:.... . .....=., ...._ -..,---=,=ll-----= •'i-= - J�-11_-.,�.�.-...- -- =_ --
WA WASHING -
WA I ER H EATER ALL TYPES IL_._.-_)1„R I-.:_ _II ... _(,r -I '-..,... - _
- WATERPIPING °'�=- -4 -_- I:__,==11-.- .:.= ll —� _ .•
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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 ET NO [
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
t..-' LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND D--• •
(_ OWNER'S INS URANCE WAIVER:I am aware that the licensee does not have th B 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 f_11 AGENT I_,U
SIGNATURE OF OWNER OR AGENT
I hereby certifythat all of the details and Information I have submitted or entered regarding this application arefrue a .accurate to the best of my knowledge
and that all plumbing work and Installations performed under the pemlt Issued for thls application will be In complia 'e with all Pertinent provision of the
Massachusetts state Plumbing Code and Chapter 142 of the General Laws,
0-_ �PLUMBERS NAME STE LiCENSEu1'2298 Ili '
SIGNATURE
MP �!'. JPD CORPORATION a1J3281G PARTNERSHiPD# D#LLC y -
COMPANY NAME EF WINSLOW PLUMBING&HEATING]ADDRESS.8 REARDON CiRCLE __K _ _ __ ____ �t�
CITY SOUTH YARMOUTH II STATE. MA ZIP 02664 I L TEL[508-394-7178 7'
FAX 1508-394-8256 10ELL I N/A i EMAIL accounts ayable@efwinslow:com T
..zozr9•' ",,e6:�U�/ rrllr;i!Gx➢'E�la�N@BLCCID
,I 00 Washington Street
�,'��1 � Boston,gi 02111 • .
'-,a www ss govlaar '
Woirkker5",9 Coarimpensation Insurance Af dia-t:B"lillil�ders/Contractoms/Electricians11Pluirilber,s •
>•uollcant fOr atio'n Please PrintLeibly.
game(3usinessfOrganization/IndMdual): {.- IVY r,+-�51L � Qtl ILA-,10 Vtai 2 eo 1`t s. .,Int.
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address: T fit' ``tiri trc;- .
r
ay/State/Zip: o4�'Llt; Erl.•`�r,"�`S�-fk k`'4�- Phone#: r-011`3 M- '# S'
ire you are employer?Cheek the appropriate box:' Type of project(required): '
U.I am a employer with 70 4. ❑I am a general contractor and l 6. ❑1_1ew constuction
' employees(fu11 and/or part-time)* have hired.the sub-contractors 7,0 Remodeling
[I am a sole proprietor or pawner- listed on the attached sheet,
ship and have no employees These sub contractors have . 8, [Demolition -
working`for me in any capacity, workers'comp.insurance. g, [Building addition
[No workers'comp,insurance 5. ❑We are a corporation and its
required] officers have exercisedteir 10.[Electrical repairs or additions
❑I am a homeowner doing all work .right of exemption per MGT, 11.0 Plumbing repairs or additions
myself.[No workers'comp. • c.152,§1(4),and.we have no 1.2.[Roof repairs
insurance required.]i'' employees,[No workers' 13.[Other
comp.insurance required.]
ny applicant that checks bdx#1 must also fill out tho sectionhelow showing their workers'compensation policy information, •
lomeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit anew affidavit indicating such.
)tractors that check this box must attached an additional sheet showing the name of the tub-contractors and their workers'comp.policy information.
tee cut employer ad is providing workers'corapensmtion insurance for ray employees. Below is the policy r rlrob site
formation.
r L "�
surance Company Name: �'13 c qiinj `k fi,s't a'tt�t(i2 cU t 3
•
)licy#or Self-ins,Lie.#: V3ai A' - Expiration Date: c-1-- r Dt .
b Site Address: 3 c�P`,r r�;tIS "C a-� ' , ;kJ-aa, - 1,-I" �" 1 City/StatelZip: c';'1 to 7
teach a copy of the worker's'comlaerrsatiou policy declaration page(showing the policy number and expiration.date).
dive to secure coverage as required under Section 25A of MGL c.152 canleadto the imposition of criminal penalties of a
—le-up-to$1,500 BB an /or u ire-3'earimprisorunetsz,as well.as civil penalties in lie form of a STOP-WORK ORDER.ad a tine
'up to$250.00 a day against the violator, Be advised tat a copy of this statement may be.forwardedto the Office of '
vestigations be DIA�.vor insurayyee overage veri oaJion, t
io hereby certify asru,e`r4k wins an4penmlties alp jury that the information provided above is true and correct. •
rlatl ice- --'' fil r' Art Date: (TA.13!I a' �s
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. mmne#: �'i�t�'lr• tk'6.77X
Official use only.Do not write in this area,to be completed by city or town official .
City or Town: Permitt/License#
ss.ringAuthorit (circle nose): .
1.Board of Health 2,Building Depar ent 3.City/Town Clerk 4.Electrical Inspector 5.1Plumbirkenspector
6,Other
CoistastPerson: . Wore -: