HomeMy WebLinkAboutBLDP-18-006085 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
1e :.,.,= PERMIT# ���1 -40 �g✓�
��'"�'�= 3 CITY � -
MA DATE
=j / OWNERS NAME
JOBSITE ADDRESS )1 y I o ��1 '
OWNER ADDRESS S - � ._.._,._..-..-.-.--
k T ELM-Rr UFAX,___�_,=j
TYPE,OR OCCUPANCY TYPE COMMERCIAL
EDUCATIONAL D RESIDENTIALV
PRINT PLANS SUBMITTED: YES[ NO(�
• CLEARLY NEW:� RENOVATION:D REPLACEMENT:1
FIXTURES 7. FLOOR-4 BSM 1 2 3 4 I 5 6 I 7 8 9 10 11 12 13 14
BATHTUB _I_LI 1.==:_{E L-_---3- -E__ E=1=1197-3[__-_a_____J
_ _ I
ON DEVICE I,.. 1.=
CROSS CONNECTION L�-��L-_...._I�-- - --- ---_ - _ -- -.... _ .. - - -1® ��
D SPECIAL SYSTEM [�_ll I__—..:L__�•__:_-: --- - :--- _ _ — - r
.I
•
DEDICATE •--_---- �------ -- _ ._-I -----1- - -- --
.•- I, I.L. - ___-_--
S OILISAND SYSTEM _1l_� _�' C. --il'___ I-_,: L. ;1_:.--_ _ ;I..
DEDICATED GA I L= _= _ I� : _
DEDICATED GREASE SYSTEM '1- ._ L.-:. _..:_,.jl__-:--: -_:L.-__._,___=_,1,=-.—+L:.;.:. .- -- -
DEDICATED GRAY WATER SYSTEM I.-:....—L:—�.'�I_. '. L7yr. _ = ' - .--1=`°"'I-`--'�I
r-- r r—•I�.:.�_-Il• _iI.17:1_._`L_ -'L_..:_'1...—_L=_.=:=i=-,.a 6:_ i
DEDICATED WATER RECYCLE SYSTEM l,.-___ql__,._ l_==_.I �•y-- _ -- �- �"-
DISHWASH -- �= � � - - - ____ _ —
'I-__:I. it _ .iL�.I: I� -�
FOUNTAIN � � _
DRINKING �—'�---- 1---- :1 .L, '1 . :._ - - --,��'?L_ ._ll � �L-_::_' _- -
FOOD DISPOSER _ ;I^T- r~ r .:L.=: _ I.,.::._. �C_� 1
DRAIN .; r____,I„_.---,�--,r��•_I:-..�_-
FLOORIAREA :. 1_:._..a:.L.�.__�'� -s�----- -- -- - — -- - -- -a
L--=--; . L:.,a : L,_.—_ L:.a__.=_ll. ...__.11 =_=:�:L .,.,.L..,
INTERCEPTOR(INTERIOR) Mr-17T-TIFT:![:,17.ti. -- ~ _ -_CHENSINK r7- ._ - _LAVATORY
KIT 1_ .J: =�,(��`1_ 11 _L ,r--- , f -`�L-._.: :i� i
_
Mil
SHO EDRAIN %I:, ?1. --- )..E.r-.. ;elf"--1L=--{----J1`
SHOWER STALL --=-C.T. -- --� �"� _ __ _ ___ _
SERVICE I MOP SINK � - - _ - _____
TOILET
1. _ _ L '1 -_II_-i-_-_JL--iL_- L._:__'L__s 1T C -
ice_-i1_-_ il__ � _ _
URINAL
WASHING MACHINE CONNECTION ®P1 �ll.._-...°( .1—__Yr=;1----, 1
WATER HEATER ALL TYPES L_:__. _ .~.F.Tr -__f-= _=il�P{ I - ® i
WATER PIPING L_ 1 I. 1E 1..__.__.,' ��--
...
OTHER I ' A' 41MI�-;1 _r-`,.1--�:L J __il : -- ;f_'.I !'�.®�
I•._-_ .-,-..-.:-"-r..v.�+-----a _-_•_ --�....-.--. -' J _-v=.0 __e.._._.. __J3< _ter_ =>iv.J
"r
cn
—T` `" - T INSURANCE COVERAGE:I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142. YES{{
L W
NO �j,
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHERTYPE OF INDEMNITY 0 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 D AGENT Li
•
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 comp) ce with all Pertinent p ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. M ���
PLUMBER'SSTEPHEN A,WINSLOW LICENSE# 12298 SIGN TURF
NAME — _
MP JP® CORPORATION(# 3281C 1PARTNERSHIP 121# LLCD# .
COMPANY NAME EF WINSLOW PLUMBING&HEATING (ADDRESS 8 REARDON CIRCLE_ _
CITY SOUTH YARMOUTH — 1 STATE MA ZIP 102664 —I' TEL 508-394-7778
.�- - - ---
FAX 508-394-8256 r. CELL NIA ;EMAIL accountspayable@efwinslow.com —�_ __— s --_— /ati- sco ��
(l,
A
The Commonwealth ofMassachusetts
fainva fI Department oflndustrialAccidents
iiti' I Congress Street,Suite 100
(...",
Boston,MA(12114 20I7 I
www.massgov/dia
Workers'Compensation Insurance Affidavit:general Businesses. • I
TO BE FILED WITH THE PERMITTING AUTHORITY. I
A licant Information
•
Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO.,INC Please]Paint ye 'bl
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH,MA 02664. Phone#:508-394-7778
Are you an employer?Check the appro ' P y:
1• I am a employer with ~ l boy:: $usis_ ---i
or part-time).*
employees(full and/ 5. 0 Retail (required):
2.EJ I am a sole proprietor or 6. ❑RestaurantBar/Eating Establishment
employees workin Pa exslup and have no •
g for me in any capacity. 7. 0 Office and/or Sales(incl,real estate,auto,etc.)
3.0 [No workers'comp.insurance required] 8. 0 Non-profit
We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c.152,§1(4),and we have no employees.[No workers'comp.insurance requiredj* 10.0 Manufacturing
4.❑ We are anon-profit organization,staffed by volunteers,with no employees. 11•❑Health Care
[No workers comp.insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
, **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy in ormati
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY f on.
Insurer's Address:23 COMMONWEALTH AVE
City/State/Zip; CHESTNUT HILL,MA 02467
Policy. #or Self-ins.Lie.#1821A
EirationAttach a copy of the workers'compensation policy declaration page(showing the policynn beate: /and expiration date).
Failure to secure coverage as required under Section 25A of MGL a.152 can lead to the imposition of criminal penaltiesofa
fine 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
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi r the albs and enalties o er ur that the information provided above is true and correct.
Ot/ P1 y
Si nature: •, r -.-- t
,�� Date: ) _ f F 1
hone#:508-394-7778tt
Official use only. Do not write in this area,to be completed by city or town official •
City or Town
Issuing Authority(circle one): Permit/License,
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen'-
s
6.OtherOffice
Contact Person:
Phone#:
t
www.mass.gov/dia