HomeMy WebLinkAboutBLDP-17-003144 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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titiirl CITY fr Km0)._/771/ MA DATE}, '- /lc1 fL PERMIT#/ P-17 MI
JOBSITE ADDRESS .;J 1 ('�y k. m,__1 OWNER'S NAME yekv,.-) iPzz/ly -7-
pOWNER ADDRESS ',--'2' PI!"(7,,i/7/ TEL ,.ZtP.2`711399f FAXe ,�
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TYPE OR OCCUPANCY TYPE COMMERCIAL D.2
EDUCATIONAL RESIDENTIAL��
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CLEARLY NEW:�l RENOVATION: REPLACEM ®ENT; f-(nnrt/ PLANS SUBMITTED: YES L..' NOD
FIXTURES T FLOOR--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB L—sh„+r_ .__..i . - 7z -;r.. ...1(,...,_ 1„:- 7-([-, �;r. ._. l- - -xl-=- - -�
'C.,) CROSS CONNECT ION DEVICE �'I ... _'r-i; , r. ._ i= #E(`,.I_. ([777I _- -';{ _. _a, r
V DEDICATED SPECIAL WASTE SYSTEM L1I ...I�.. . '�. [ . F- +l__.:,.tr-. ;I_ j3.}C.-71 ___ II___ ;F iTE
DEDICATED GAS/OIL/SAND SYSTEM I__ ) . ( .77 1 . ,r�: i,(- :I I _ _ rr I - g(`-t�-1r-
rVJ DEDICATED GREASE SYSTEM [. . I.y I 1 I„T -.11, ,. S�_�..-ii ii_____J __A, _ ..II--- -- ( ;rJ�_.L—r
DEDICATED'GRAY WATER SYSTEM 1--;'1 - •[_ I •f,ll_..- 1_._.,::..-<;L i�1f_ t1:. .:- 'r �1[. . ..1.. , r,-!I T T
DEDICATED WATER RECYCLE SYSTEM E iI r :;(��- � 1 _ 11 szl ,;'� r ,3I,,,_.. ;f f
r DISHWASHER I:n-,,, I . .. I 'r _} -�., `1, r.,. [T r"_rr�r"`t---
DRINKING FOUNTAIN r. ( _lr `r, (' 1ff 3(. ( 7 .r i . 1--..__.I1_I—:'1._ _:_
FOOD DISPOSER I_,... �)'__ ;1 F.' i17: ir- ..:r(: °E I_ '1_ 'I(--11�_r- r- -
,. FLOOR/AREA DRAIN . ...;r ,�.L - ( i E�ii ,I (w . r r: ',I. •1 r�. r. .
INTERCEPTOR(INTERIOR) 1. II _. ..1-,1� .1_ !I ;r- -I(--'[, I I : ,1 ._�ir^-[_�-[,:.=^a:`
KITCHEN SINK I---- 1 - it I r-i�l._ —.-,.{- _
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LAVATORY C-._i[--il_ .'C (... l' .:,11 -."4rn •E7I--- 'f.____F-7`;---
ROOF DRAIN L_-ii i ---!r [ - i .11� . .,F.:7;1 .—ir (— . •7E71
SHOWER STALL Ir-,<J[ ,.:ir.;:.._. 1 I[:..-..,,3I-,TP-lr-iI_.-!._r- i [_-.,.._
SERVICE/MOP SINK _e. . 1r . IE .. -3 . `±I 17-)[ 11,77.11., ,..,A . _ '' :-^?
TOILET i- 11 'i II a�._ .-.J _ . d _ _11V _Era._- !1 ,F j.
URINAL _ir _ i(-. '7, I[ _I r `1[ ( -�
WASHING MACHINE CONNECTION it 1 . i1— ..... __,11. .. I1 1, II. ---7 1. II. ;,I___177)--JI
WATER HEATER ALL TYPES c ,� il_ .__, i q--_ 'I- ,'I . .__I,. .. .17__..,=il._ . L._. .-:r- r,, ._'� - ,._I ---'1-=, .._.
WATER PIPING I Ir-71 Tr Ir ! ..�1 :. - it >r 'r [^tzr i .. '[.. kl _:
OTHER �IFi. I E �-- -�171r-,,.,_?r -;I .I . I- _ I__
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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 Ed NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L1 OTHER TYPE OF INDEMNITY 0 BOND 0 -
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 end information I have submitted cr entered regarding this application are true 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 ance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /� /y
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PLUMBER'S NAME STEPHEN A.WINSLOW ]LICENSE# 12298 SIGNATURE
MPO JP[U CORPORATION 0# 3281C ;PARTNERSHIP#[ LLCI# _ ..
COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH II STATE MA ZIP 02664 _- _ - TEL 508-394-7778
FAX 508-394i 56 CELL I N/A 1 EMAIL accounts payable@efwinslow com _ _ 7
5"� 6r Hf
01
;51 Office of Investigations
600 Washington Street
Boston,MA 02111
www.niass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers kuplicant Information •
n Please Print Legibly
same(Business/Organization/Individual):E .Wt,,5I Ow QI‘lw.101,1c L l�{a4
kddress: C3' Q track) l,irri
2ity/State/Zip: kv1 `�cv o fit• iy� Phone#: 3 i%']'1'
ire you an employer?Check the appropriate box:
I am a employer with '70 4.ElI am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction
❑I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. []Demolition
workingtfor me in any capacity. workers'comp.insurance.
[No workers'comp.insurance 5. ❑We are a corporation and its 9 ❑Building addition
required.] officers have exercised their 10.0 Electrical repairs or additions
❑I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),and we haven 12.0 Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.] 13.0 Other
ny applicant that checks box#1 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 a new affidavit indicating such.
mtmetors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
rm an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site
formation. /�
surance Company Name: (�'rrevi,.1 Ck.it-t1o,11 3—,n). ,,t ell-se
licy#or Self-ins.Lic.#: \$a I A Expiration Date:yH I— o�Ui •
b Site Address:.a3 CCSAAM0v v a-11h A. Ct,e.My {• NI I City/State/Zip: 00'4 t,7
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
flare to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
se 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 da a ainst the violator. Be advised t at a copy of this statement may be forwarded to the Office of
vestigations the DIA for insura, overage veri ca on.
to hereby certify un ns an penalties o peeju, that the information provided above is true and correct.
grtatu Date: la)3 I i aot �
tone#: 1)%•35y,777X
Official use only.Do not write in 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: Phone#: