HomeMy WebLinkAboutBLDP-17-002874 •
L' MASSSAChIUSE T T S UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
J•
� CITY} �� -_ 1 MA DATE PERMIIm _
JOBSITE ADDRESS P; OWNER'S NAME jodE _1- k
IED OWNER ADDRESS nX r<-, TEL3GiXl-__,_._�
TYPE OR OCCUPANCY TYPE COMMERCIAL 1-1EDUCATIONAL U RESIDENTIAL_
PRINT
CLEARLY NEW:U RENOVATION:0 REPLACEMENT:[a_/ PLANS SUBMITTED: YES ' NOW
FIXTURES 1 FLOOR--I BSM •1 2 3 I 4 I s 6 7 I a 1 9 10 11 1 12 } 13 1 1.
BATHTUB IL___-(C _) :IC.--`I( --`I_,,.J - L'--1I.__f_... , .I_ VL,-IC_ -,.S
CROSS CONNECTION DEVICE _-.��
R NN N I �.._'!I:_-- �---- I_. _:IL_...,_�C__..klV�ri.:-._�Ilv.._:'1—.:...:-�C-`-1--- `-(�.�I___—'U.�,-.
DEDICATED SPECIAL WASTE SYSTEM IC... i-.-.1L. If_ I E_3I,R 11-7,7I_T .II�_I_— 1._.__ .ii,.„.__ 1-1 .11._.:1_-.,J
DEDICATED GASIOILISAND SYSTEM 1'71._ ':1 ,C :1=11t• - h-V•7'1.:171� '11--:.: C- a.-_._?I 'll.= _,..'•C ~.
DEDICATED GREASE SYSTEM _ �_
IL_�rll-. . . #L . . �I ;�._—:—III:.--•.�I�:-'1_=-41 —?=.:-1----'t.._f►----.=11___!
DEDICATED'GRAY WATER SYSTEM i__Ji..... .11._ :..IC.:7•:-2IC—_^C__,: 1_.,_-1_=—'I r-fir •-'I• 'i:.__._: I=.�
DEDICATED WATER RECYCLE SYSTEM I til_____ET- __:jl==�_C__T •.:?I— 1:71.}L• _-�_:1-�._-j-�I.-_.ul:-_ __ _L
DISHWASHER ;,( _IC_. Il,•77II.-..--C_._4t:-.::-.C-7C_,^1._ I_-,->_.11-_^_ir.:77)---._._ L__.__i.
DRINKING FOUNTAIN 1�}I1 _._�I,=r_7_:1C-. . I,h.,_>C3r. L,.-.1I GI (� __11- I ' .I'C_=_}
FOOD DISPOSER 11 ill-.:- :=r-. 1. .T -7^`11,-.....'.I_,- ....OTT'1:77(1__. `•I ...:;[. ..'FiL._.;__�C
FLOORIAREADRAIN U al�--.-�Il.=- 1_-.=_ L_:=_'�=—_ri.._r-.h ,( _ -'i1:=---"1:.:.::'l_ • ' --... I _. -
INTERCEPTOR(INTERIOR) It :C ,il^_11_ '1 .:L_=_.-_iC-;'L+II. II, j1,.._.=a>C. _sE
KITCHEN SINK I_—_'f, 1I-- `I__-_,(:. .71l< i1.. f�I•• ;1-�_ _.I _I ':r X._- I
7-7
LAVATORY - __.1:_�'1:-- •n 'I•_ .I---:=:._[:..-''I-----_ - ,1.--_DI-'L ;1..
ROOF DRAIN I I _1-. ;� '[- ::. L tl::__J ',IM1r.. ., !;[.--`[I. .....
SHOWER STALL 11_-.._-JE___11,:_1 i I-.-_iC_--.,_ 1 ~__tl_. . {I--_ `-C _____-�— I--� �;
SERVICE I MOP SINK 1 _ _; __ -•:
Imo. _I_ <,C_ I�-11—. l__:.___.fl— ' (-,L_-1_,.,IC C_...._`I �.
TOILET • I 'IC- - -`1 - - `IC--'1=_=..sl_—�� 1_=>I�L._— -tC... __'Ilil- r--`L_
URINAL _.......I[. .'1_,_ t1- t1�-_I =._IC__='L 1T._. ;C ;1 L___ =E: L_-:
WASHING MACHINE CONNECTION i.--_--.-.-.11- ;1 . ,_ �JrI,_-- .-,_..II' .. 'I..:-. .�I..-. I C-1I:_......;LC--1I.,.-• -.1�_-
WATER HEATER ALL TYPES ;I— IL 11 _II., t . I,__s --
WATERPIPING . . __.. J�aC-�I(- `IIC ... _``�I..:. . _'r-. .'i. ',I.: : 1. � (—
OTHER ....--.. __1 .. _ YC-.I--'I_ st-- -:' ---.-~:•I. _ (—i1-41_ - r. _ . .0
_�. ___ - - - 11 :=_ E = _ 'y-„- mac `I- 1_
-
f.
INSURANCE COVERAGE:
• I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[i NO L.
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1 OTHER TYPE OF INDEMNITY J BOND I]-••
OWNER'S INSURANCE WAIVER:lam 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 Li AGENT U
•
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are fru: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 co/nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r / %%
PLUMBER'S NAME S T EPHEN A.WINSLOW ii LICENSE_ 12298 -- SIGNATUR
MPU JP CORPORATION 013281C IPARTNERSHIPU#1---1LLCD01 -
COMPANY NAMELEF WINSLOW PLUMBING&HEATING. ADDRESS 8 REARDON CIRCLE - 1
CITY SOUTH YARMOUTH �STATE MA ZIP D2664 =_- TEL b08 394 7778
FAX' 608-394-8256 }CELL La `EMAIL accountspayable@eTwinslow.com
.�1 0 - 'E-.( ' 60 .0 1437o 3ZI
11� l ��Jls�c Lj AM'neagrle&V,
600 Was. hfngton Street
Boston,ML4 02111
Wwwamass gov/dl&dr
Wo,rker$9 Compensation Insurance Af> davit:Buildders/Coy tractorsIE¶eetrrieians/Pllumbers
rpiplieant Legibly
n l d
>IRme(Business/organization/Individual): f�3�i.E t;rl;1 ;,,lelF
A1ddress: �.' t�f'i t a m
-my/state/zip: k , ;c v�,.F i t. Phone 4: `SOS YALI-iern
ire you an employer?Check the appropriate box:' Type of project(required):
I am a employer with `70 4. L, I am a general contractor and I 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
❑I am a sole proprietor or partner- listed on the attached sheet.. 7•-[]Remodeling
ship and have no employees These sub-contractors have . 8. n Demolition
working Vor me in any capacity, workers'comp.insurance. 9. Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0Electrical repairs or additions
❑I am a homeowner doing all work .right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. • c.152,§1(4),and we have n.o 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 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.
ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
Irri an employer that is providing workers'compensation insurance for ray employees. Below is the policy and job site
formation.
•
surance Company Name: AMw' Ohl ., ely
ilicy#or Self-ins.Lie.#: 1 A. - Expiration Date: c—1 r (7[`��
b Site Address:D.3 `—Ornr'scY4 i1/4r-e a ry Cv,e341401.11 City/State/Zip: Ord 4
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
duo to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
ie 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 day against the violator. Be advisedt ,at a copy of this statement may be forwarded to the Office of
vestigations I th D or insura lee overage veri `ta4ton.
I
to hereby certify un eYi epains an/d penaliieS ofp July that the information provided above is true and correct. •
,Hato 1f ; Date: Q%:1.
311 i'
lone 4: f • 9 -7;7
Official use only. Do not write iii this area,to be completed by city,or town official .
•
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: • Ph one#: