HomeMy WebLinkAboutBLDP-17-002115 K. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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''--• 1194. CITY ,,,j 24r 7 L1 -~:M� MA DATED(' A /(� PERMIT# p i7- o //J-
sN JOBSITEADDRESS (J /J/,/d f /t'd1, 17 / 1 OWNER'S NAMEALdr—Zf 1
III) OWNER ADDRESS I y ,C i j TELO 47 *,7 .6 1FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL D RESIDENTIAL 12
J PRINT
CLEARLY NEW:El RENOVATION:LI REPLACEMENT:® PLANS SUBMITTED: YES E. NCO
FIXTURES 7. FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1•_,I[. I_-1 _ E-^';(.-:117 .1[7. iE_,. 7..1-,. -. -:1- - - '
ti� CROSS CONNECTION DEVICE I____';I . . 1- L :.;- �;(.. ._.IF- .fil -�I- �I _ j1777 _'I_: I .-
_DEDICATED SPECIAL WASTE SYSTEM I__- ,1I . ..,.I I- I7 _,.)Ll .a I. - ;I---_ _al:, r.----:- T 1 'I __ -? I__,_i
v DEDICATED GAS/OIUSAND SYSTEM F_'I--., , (-� 1^— 1 ,_� l I� 1h r _ (- 17--"i -!)— 1T-7
---. DEDICATED GREASE SYSTEM F--'_n'I .177177 1 t 11 ,- i17 i) f< 1 I I __ _ r 11_-_ _ -. -'�-
DEDICATED•GRAY WATER SYSTEM __I--.. r r _,-,F. !I J[: 1 71 .7E-1( _•`E. {I
DEDICATED WATER RECYCLE SYSTEM L. ._I ___ - r L_ 1 1 1I- ;I _ i[-,- .�. 4 -:..1_L _fif. r
DISHWASHER • I, _ I I _ I— i 4 .,:1 '(�-' I L_:
DRINKING FOUNTAIN [p._ - - .. (- � . ,I-._ 17 E ii .(-Vf-77:( r .--' I____z_
'I_FOOD DISPOSER • L..I7� r _'r- a._.�;I ?[_._
;I_ ,.: _� I___�
-- I . ._-,I. 1� r
FLOOR/AREA DRAIN I .w�_., ;L_.... Fu ��-_._.::.T. :17u;I_. 11 - i.. . --,1l-.1_ r
INTERCEPTOR(INTERIOR) I II,-; -11. f - -I_ .,.)1_ . .. ;r--_ -II . .'(_��1 � I. �I....- ^[- ;G-.z:_R..-'
_KITCHEN SINK [_-- 1_ -. -;I. _; FT1.T[_ I '� _ _7 . _''I ( �_ r__-__IT 'IJ • I
LAVATORY I--—`[- iH --1 1TTr-II--
;[--7I-_-- `L---L '.[T,.._;I
ROOF DRAIN L t 1 1--[ ' _. II ';17'1 i t [--
SHOWER STALL _-,,.-a.11 I I. . , __+- ._ _.1 . - I F-'[. 1[-. 1=1_—-:17-7F7a
SERVICE/MOP SINK l[771F-1- ;L .:;.. _ ll y.. _11 ) l[7.7 iI - L -L --C____ti�'.
TOILET L.__ 1
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.-. � T. I + - '_ h,_ Jr,_____
_ i,-T I 'I _ cL_ , _ _
URINAL I�TC ri .:171 PTT[.l _;:T1 . E7I _ -s= * L_r
WASHING MACHINE CONNECTION ( 11 F IF— I�- ;LT Il ' -`i -- ,I -,1-
1k,r__i:)
WATER HEATER ALL TYPES Lr it _. T7 '� ;L '�7-_.. ,I., 1i1_ 1 _. -_T- t„..._.,1 F- •
WATER PIPING [,,__1f I�_.'I-7-l[7 , :e.r-,,,I `II [ 'I ' - 7. - '1 .. i- 1--
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OTHER - --- . T- � - -,, r �• _. .'I_. ,1 . . -�r-ii�-1_ . '[�-.
j INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ed NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY® 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 ® AGENT 0''
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are tr e 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 ilance with all Pertin nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. •
i. _ „Li e Q'€-'
PLUMBER'S NAME STEPHEN A.WINSLOW ___7 LICENSE# 12298 SIGNATURE
MPO JPO CORPORATION El# 3281C I PARTNERSHIP LI# LLCL,]#1 4
COMPANY NAME!EF WINSLOW PLUMBING&HEATING i ADDRESS 8 REARDON CIRCLE a�l
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CITY l OUTH YARMOUTH _,�� .STATE MA ZIP 02664 TEL 508-394-7778
FAX 1508-394-8256 1 CELL NE__ �1 EMAIL accountsayable@efwinslow.com
Department of Industrial Accuaents
Io_.
,�got=47 Office of Investigations
G WiIiil=
=114_;;y 600 Washington Street
Boston,MA 02111 •
. u�`' www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information CC� f ��11 t 1 Please(l Print Legibly
Name(Business/Orggl1anization/Individual):E'r•Wt✓�51 s.0 Q[J✓•.IOwtci L ly<0.h✓�t `e.)I✓IC.
Address: � KP craw) CImie- Ut
City/State/Zip: �o.s s' v^c--t-i^ NPr Phone#: `50)-39`i-1T7'l
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 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
!.0 I am a sole proprietor or partner-
listed on the attached sheet.t 7• 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its 10.0Electrical repairs or additions
required.] officers have exercised their
I. right of exemption per MGL 11.0 Plumbing repairs or additions
❑I myseam'alf.
.[No workers'e doing all work c.152, 1 4,and we have no12.0 repairs
[No comp. § () Roof re airs
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
lay applicant that checks box HI must also fill 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.
im an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
tormation. I�
tsurance Company Name: A'C tat-,•s C-L)�� ,..Lnstisrck l co.- C ul'"-'atv`j
olicy#or Self-ins.Lie.#: \S a) A. •
SS 11 Expiration Date: t—l— ant-)
Ib Site Address: 3 granw-e0-'i y Ct'estb' FT\, City/State/Zip: 6,-)1-1 to 7
.ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
allure 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
Cup to$250.00 a da a ainst the violator. Be advised at a copy of this statement maybe forwarded to the Office of
tvestigations the DIA for insurae-.overage verijlon.
do hereby certify un'e s an1 penalties o pe jury that the information provided above is true and correct.
ignatuT:: /tr� Date: ta)31 I a015^
hone#: Y,..35`i-777d
Official use only.Do not write in this area,to be completed by city,or town official.
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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#: