HomeMy WebLinkAboutBLDP-17-002979 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK / `I- '� /y/gyp','•7� �'�! 7
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,a��� CITY,S®K,j�e
� � MA DATE�1-,3c',�/,�„��,,.�PERMIT# �
, JOBSITE ADDRESS _:..3"/_ ca m,e,,,, 5`J^ ._. .._ . .v.I OWNER'S NAME Id- ..t� _C
POWNER ADDRESS , ' ��,?f�3 1 1 ✓'z.�•_'J ,,,.,� TELE77Y7a,�7yo'a !FAX' . .. 1
TYPE OR OCCUPANCY TYPE COMMERCIAL ! EDUCATIONAL 0 RESIDENTIAL 1g
PRINT
CLEARLY NEW:ED RENOVATION:,- REPLACEMENT:RI PLANS SUBMITTED: YES 0 N0E j
FIXTURES Z FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB - i 1111111_ .. _11111110110111..
--- _ _- r r JIM -,
CROSS CONNECTION DEVICE v � ' _ _ i
DEDICATED SPECIAL WASTE SYSTEM I ,tr _ — -
DEDICATED GASIOIUSAND SYSTEM ___. - ___ givipwimmw`
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM Iiii iffilITfr' 'r ='
DEDICATED WATER RECYCLE SYSTEM !, ----
DISHWASHER � � ' i
DRINKING FOUNTAIN 1 1I� 3- ( ---- -
FOOD DISPOSER WININEIMMINIMMINININIElt
w FLOOR/AREA DRAIN 1— III M1111111111
vo INTERCEPTOR(INTERIOR) f MIW � ® M
-. KITCHEN SINK i .- :.- ,
N, LAVATORY
sn ROOF DRAIN � �I _
SHOWER STALL I ' ' `
SERVICE/MOP SINK IIMWIRMIIMIIIIIIIMINIONFI_ —
TOILET i. ,---.
URINAL �- �
WASHING MACHINE CONNECTION i �� � ^ �
WATER HEATER ALL TYPES w "z'"° a "°*
OWATER THER PIPING ® it1livid11111 -
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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 El NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Lb.1 OTHER TYPE OF INDEMNITY El BOND L
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 Cl AGENT I_ ,1
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are tru 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 II Pertine t rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A WINSLOW LICENSE# 12298,_.,.._. SIGNATURE
MPS, JP CORPORATION(Q# 3281Cpx PARTNERSHIP( # _y, LLC( #
COMPANY NAMEFE F WINSLOW PLUMBING&HEATING ADDRESS 18 REARDON CIRCLE J
CITY SOUTH YARMOUTH
STATE I. „MA j ZIP 02664 1 TEL(508 394 7778 -
FAX[508 394 8256 J CELL CNIA EMAIL I accountspayable@efwinslowcorn ,, ,, ,,,,
S �d I
at
*- Department of Industrtat Accraenrs
R
_,'l1ii� ,t Office of Investigations
=i'nl=,y 600 Washington Street
SITE' Boston,MA 02111
www.mass.gov/dia •
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information C f ) 1 Please Print Legibly
Name(Business/Orlglanization/Individual):L.Y`.IN 1,NS 1 o,j QtVw��7 iv'te{ ,...in✓mot, crfl,f rtt.
Address: (4oann C irr1� (� Uf
City/State/Zip: Sou kh kitct-w,cr.. % Npr Phone#: `50b-YVi-177 •
Are you an employer?Check the appropriate box: Type of project(required):
,!{ I am a employer with "70 4. 0 I am a general contractor and I 6. 0 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.t 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working forme in any capacity. workers'comp.insurance, 9. ❑Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its
required.] officers have exercised thew 10.❑Electrical repairs or additions
i.❑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 no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
\my applicant that checks box al 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 him outside contractors must submit a new affidavit indicating such.
:oonttactoro that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
tm an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site 1
lrormation. /nl�—�
eurance Company Name: (�YY()'..J My 0-11 f u21 it CO_ \ tr1nnR'l''wi
olicy#or Self-ins.Lie.#: \7•a I A' . '1 Expiration Date: —I— and"1
tb Site Address: 3 G3nnrwa lw-eo(r > , Cc�e.3 'MI City/State/Zip: COr-1 to
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
l'up to$250.00 a da a einst the violator. Be advised t at a copy of this statement maybe forwarded to the Office of
•
lvestigations the DTA for insurapee overage veri ylon. I
do hereby certify un a airs an 1p:allies o pe jury that the information provided above is true and correct.
iRnatiS'• Date: l o-13 I l c1016-.
hone#: .SL1%.354-7 77D
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#: