HomeMy WebLinkAboutBLDP-18-005368 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
,. =_-4Ai MA DATE U��'PERMIT+ b �� ���Od i �C^
'= CITY 1
JOBSIT ADDRESS f. 1 OWNERS NAME�� r _ _
MINNIA
OWNER ADDRESS S�ta TfI C'' — _ __ _1 TEL " t: n FAX-- —I
TYPE OR
OCCUPANCY TYPE COMMERCIAL EL1 EDUCATIONAL [ RESIDENTIAL[
PRINT PLANS SUBMITTED: YES D NO
DCLEARLY NEW:[, RENOVATION:0 REPLACEMENT:
FLOOR. SM 1 2 3141_ 4 5 6 7 E 9 10 11 ®®�
FIXTURES 7 4 B ®L_-- 1=I®®M
BATHTUB
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CROSS CONNECTION DEVICE - L-_:_:;_---_=_-•I^. _�}L.:__._' .�w�_:..v�'.:-.._... 1:.-_. .��h�-'Ir--`
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DEDICATED SPECIAL WASTE SYSTEM JI_ I___ ...;I_____mmTI-- I -=_ �=�-=• 1--_ I.:==1-- --
' DEDICATED GASIOILISANDSYSTEM [.-- 1L..__-�--__=t ___- -F..- - {�--=--=31 ,. =IT•`3�1-- ENtim os®
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DEDICATED GREASE SYSTEM =--
DEDICATED GRAY WATER SYSTEM ......,71..:_
DEDICATED WATER RECYCLE SYSTEM (,T 1. [ (____;__1-11 .,_„)[ 7.7.11-- _' �®
TINIMEINININ
DISHWASHER
DRINKING FOUNTAIN ft
FOOD DISPOSER [ _ .1 _.I L - - _ `-
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FLOOR/AREA DRAIN _ -1= i1 I_= I ._..-5[_-:-`1- -+1= I- �, ®®®
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INTERCEPTOR INTERIOR [_--,'r�T.I:. C- 1,=.--__:1[ __.__
KITCHEN SINK 1�— � '�^' �-� '---
LAVATORY :F.::-: - - - ®®®®®
MININIMINIMINNOIN
ROOF DRAIN I .
SHOWERSTALL L [-I-----:Lam;E -1I I- +t l--___% _® ®®
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SERVICEIMOP SINK r_-._,_�1:.___._:�I-__:
TOILET 1..---- -- -�7- 11_:.._ _
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URINAL j.. '.L._.__ _ [,�_- j .', -. 3_ __® ®®�
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WASHING MACHINE CONNECTION ..--,_�1 �Lf-.- . '__..___-
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WATER HEATER ALL TYPE :-T}I =f. I._�'[._ L '[_-- IC I � 'l.._.._:.:.f- . f -IL ; }
WATER PIPIN_!�_________ __---�� ;f -.FT:: - _'It ---1----- I__..._ ?_ 1-1-11 = v J
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L`_ '� "-� INSURANCE COVERAGE:
1 have a current lia bilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES tri NO LQ
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY
OTHER TYPE OF INDEMNITY 0 BOND D
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 0
Massachusetts General Laws,and that my signature on this permit application waives this requirement. -.3
CHECK ONE ONLY: OWNER D 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 fr and accurate to the best of my knowledge
and that all plumbing
State Pork anding Installations
s aCodlll and Chapter performed
underf e the e General permit Issuedfor this application will be In co an e with all Pertinent provision of the
Massachusetts
s.
STE THEN A,WINSLOW _ LICENSE# '22 98 SIGNATU
PLUMBER'S NAME
le JP® [+,#
CORPORATION 3281C __ 'PARTNERSHIP D#� -1LLC 'i#=___
COMPANY NAME EF WINSLOW PLUMBING&HEATING ;ADDRESS 8 REARDON CIRCLE --
STATE I MA j ZIP 02664 J TEL 1 508-394-7778 - -
CITY SOUTH YARMOUTH
' �___---EMAIL�accounts a able efwinslow cam .�: Tl-
FAX 508-394-8256 . CELL NIP A 1 ntsp y-_@ �y`-T
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The Commonwealth of Massachusetts
J Wi t,
►.�
—,��
*+ii' '� Department ofdndustrialAccidenfs
—" I
Congress Street Suite 100
� Boston,MA02114 20I7 i
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:general Businesses.
TO BE FILED VVITII THE A IicantInformation PERMITTINGAuzHo�tzxX. f
•
Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO.,INC Please Print I,cEibl
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH,MA 02664,
Are you an employer? Phone#:508-394-7778
Check the appropriate box:
1.0 I am a employer with °—� Business Type(required):
or part-time).* �—employees(full and/ 5• ®Refail
2,El I am a sole proprietor or partnership and have no 6. ORestaurantBar/Eatin
employees working for me in any capacity g Establishment •
7. ❑Office and/or Sales(incl.real estate,auto,etc.)
3•® [No workers'comp.insurance required] 8.
We are a corporation and its officers have exercised 0 Non-profit
their right of exemption per c. 152, 1 4an 9 0 Entertainment
no employees. ' insurance
we 10❑Manufacturing
[No workers comp.insurance required]*
4.❑ We are anon-profit organization,staffed by volunteers,
with no employees, 11.®Health Care
[No workers'comp.insurance req.] 12,
Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compee compensation policy information.
**1f the corporate officers have exempted p themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box
X am an employer that is providing workers'compensation insurance for
my Insurance Company Name:ARROW MUTUAL INSURANCECOM AN employees. $elowisthepolicyinformation.
Insurer's Address:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL, MA 02467
Policy. #or Self-ins.Lie.#182 f A
EiratioAttach a copy of the workers'compensation policy declaration page(showing the pohcyDaumberD1/201
Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of
fine up to$1,500.00 and/or one-year' and expiration date).
Y 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 Officeal of of a
Investigations of the DIA,for insurance coverage verification.
to the of
X do hereby certij, the ajihs and enalties o peljuiy that the information provided above'
Si nature: \ , .,,- is true and correct
hone#:508-394-7778 Date: f
•
Official use only. Do not write in this area,to be completed by city or town official
City or Town:
Issuing Authority Permit/License#
1.Board of Health(2,Building onbepartment 3.Cify/Toym Clerk
6.Other 4.Licensing Board 5.Selectmen's Office
Contact Person:
Phone#:
www.mass.gov/dia
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