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HomeMy WebLinkAboutBLDP-19-001975 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 'r _ a PERMIT `�U J = i CITY Vt. MA DATE JOBSITE ADDRESS �/0 1 0 1 I f I' h �(�1 VP ( OWNER'S NAME ;FAX_�I p OWNER ADDRESS` t TEL MOM TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL J RESIDENTIAL� YES N0� PRINT PLANS SUBMITTED: ' CLEARLY NEW:D RENOVATION:[ REPLACEMENT: ��®® ©�©© 6 7 6 9 10 �® FIXTURES FLOOR �® BATHTUB � ` CROSS CONNECTION DEVICE I- __ ®� ®®® nm DEDICATED SPECIAL WASTE SYSTEM (.-__..=:11.-- �® ®®� Q ' DEDICATED GASIOILISAND SYSTEM ® M®� iN (Y) DEDICATED GREASE WATER ®® L�®�®® ia Ln DEDICATED GRAY WATER SYSTEM '`,� DEDICATED WATER RECYCLE SYSTEM ®® N �M���® �®® DISHWASHER C__._. I_:..,..__.��®®� �® �® DRINKING FOUNTAIN �r—�--_'®�®®� ®® MININ ' FOOD DISPOSER ® �®��� �®® FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR ®M� ®�®nlemennwramosemeM��® i ®® LAVATORY ®III®M®®®®®INONIIIIIMINEW ® ® ROOF DRAIN ®�m��m®�® SHOWER STALL IIIRMINIMINIIIIMMIMINEMINIMMIIIIIIN SERVICE I MOP SINK ®®�®������®®��® 1.1 TOILET URINAL ®®®®®MM®INIM®�� ® MINPOINI WASHING MACHINE CONNECTION ®n �®®®o ®� mapr • WATER HEATER ALL TYPES ®®MM ®®NIUM®®®���W® MWM WATER PIPIN — _ ---- ®I���'®®®�®� OTHER : =-==-- •f i®®�®�MI®®®�®�®® ------- WININNINK __ __ !- -:MI®HNC®®11111®®®®®®®® L----= -=:_ INSURANCE COVERAGE: I have a current llabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES La NO Ej IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY El OTHERTYPE OF INDEMNITY 0 BOND U uO OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the f Massachusetts General Laws,and that my signature on this permit application waives this requirement. W • CHECK ONE ONLY: OWNER U AGENT U (� SIGNATURE OF OWNER OR AGENT a and accurate to the best of my 1 I hereby all pluming ofthe nd i stallatipns performed under the permit Issued for this applicatios npwill be In arlication plian a with all Pertinent provision of the 9e and that all plumbing Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ilTEPHEN A.WINSLOW LICENSE# 12298 SI T w ` CORPORATION[# 3281C ,PARTNERSHIP U# LLC + _Jr_--' MP �i JP® COMPANY NAMEt EF WINS PLUMBING&HEATING rg ADDRESS 8 REARDON CIRCLE _ _ CITY SOUTHYARMOUTH 1 STATE MA ZIP 02654 _J TEL 508-394-7778 ---�6' i e efwinslow.com 1 It EMAIL accounts a ab] I ��-- —_--� • FAX 508 3 .: CELL NIA . 3 , A The Commonwealth of Massachusetts l�h department of Ind usty'iazAceidents F 1 Congress Sheet,Suite 100 • Boston,1114 02114-2017 I Workers' �'�'�'Y'ta� gov/dia Comp ensatien Insurance Affidavit:Veneral Businesses. A17A11�t InOrinati0rl TO BE PILED'WITH THE PE DOTING AUTHORITY. Business/Organization. please Print:Le IN E.F.WINSLOW PLUMBING&HEATING CO.,INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664• Phone#:508-394-777 Are you an employer?Check the a 8 I.0 I a e appropriate box: Business m with 10 employees 'pe(required): 2•Uorpart-tirne).� --- (MI and/ 5• El Retail Zama sole proprietor or �-7 employees working partnership and have no 6. 1 1 Restaurant/gar/Ea g Establishment ' g for me in any capacity. 7. ❑Office and/or Sales [No workers'comp,insurance required] incl.real estate,auto,etc.) 3 ® We are a corporation and its officers have exercised 8. Non-profit their right of exemption per c.1 9. ®Entert ' no employees. §1(4),and We have auunent • [No workers comp.insurance required]*' 10.0 Manufacturing 4.❑ We are anon-profit organization staffed by volunteers, with no employees, 11.0 Health Care [No workers comp.insurance req.] 12.0 �y applicant That checks box#1 must also fill out the section below showing their workers'compensation satin . **lithe corporate officers have exempted organization should check box e p themselves,but the cor poration has other employees,a workers'compensation policy I am an employer that is providin , mpensatien policy is required and such an Insurance Companygworkers compensation itisurarice or my employees. Name:ARROW MUTUAL INSURANCE f Below is the policy information, Insurer's Address: CO RANCt;COMPANY MMONWEALTH AVE City/State/Zip: CHESTNUT HILL,MA 02467 Policy#or Self-ins.Lie.#1821A Attach a copy of the workers'compensation policy declaration page(showing Attachtoa secureoy ewor as required'compensation under Section y25Ade la Expiration Date:0 number01/20 expiration Fail up fo See. o erage s e ar i the e impolicy f and nal penaltiesdate). ofa upmprisoruuenf MCTL c.152 can leadto the t$position of c ' fi e to o$1,00. day d/or one-y violator. 'as well as civil penalties in the fo b En af a Investigations of the DIA for insurance coverage advised that a copy of this statement may bed STOP WORK ORDER and fine ag verification. Y be forwarded to the Office of 1'do hereby certi r the al sand exu�tieS o penury that the information provided above' Si afore: ,4 zs true�� and correct hone#:508-394-7778 • Date: / I31 i I • Official use only. Do not write in this area,to be completed by cic ort City or Town: ' own official Issuing Auth ority(circle one); Per' icense 1.Board of Health 2.BuiIdingbepart$enf 3, 6.Ofher City/Town CIerk 4.Licensing Board 5.Selectmen's Office Contact Person: Phone#: www.rnass.gov/dia