HomeMy WebLinkAboutBLDP-18-004108 — MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Ta air- " CITY4 Tf'�n Lr' ( - ([ I MA DATE PERMIT#/g P-17 'I g'
t_d_fixi
JOBSITE ADDRESS r t OWNER'S NAME _
OWNER ADDRESS n9[; / TEL56g-36a-61X1FAXI I
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL r RESIDENTIAL
PRINT PLANS SUBMITTED: YES[ N0� ��
' CLEARLY NEW:( RENOVATION:U REPLACEMENT:
FIXTURES 1 FLOOR-► 1 2 3 4 5 6 7 8 9 10 I 11 12 13 14
}
7
BATHTUB - EI=._ tL_- -_ --=I - =-_ = 3fiI—_
CROSS CONNECTION DEVICE L-:_.:._: I•___..�, -k�==-=-='' ••-_ L:.-__:-_L:------' f
AL WASTE SYSTEM II=_•---I-- :1= =-_' _-.`L-•._ - -_ -_ - -_-_ - - _
DEDICATED SPECIAL --
• SYSTEM I_. � I_ -._.. :1:.-_.._ -
DEDICATED GASIOWSAND _ �[ �-
DEDICATED GREASE SYSTEM MI_ I_ . _.I=..:E�. _::L_._- IL.__-__A___-�t _1I_:-:::_it_..,_1I-=-z:_• ____ : .-
DEDICATED GRAY WATER SYSTEM F�3L_. ._ r- r._..il_..,.-;L_,_:._<IL_ r #r•,.,... i_.__.IL. -- - _
DEDICATED WATER RECYCLE SYSTEM ®7 7 al= _'r=,==AIL_._= ,L_—L_- -�-L_T-:i=_..11_`-lr` 1_,__— ._ 1
DISHWASHER ML_:.:•- F. `tl - �'�.:..;..�I -- - _---- --- - -- = =- -_-
}
DRINKINGFMN �` -_,vii�.�-`" - :_. - _
•�I. i
FOOD DISPOSER ®®1 (`- - - ___II , ___ t
FLOOR I AREA DRAIN ----= �-° .1:— - _
INTERCEPTOR(INTERIOR) ®�==47 �_.'- _.__.-. -_-_t�.__�:-:�-1i _ I �='I- III
I ll. L i►-
SINK I ;I,._,_ r ,-.1_IL -'1 :I E ,.
KITCHEN �I I I . �I II.._,..1,iL l-_2'I. _ I : ( _ ,I _z- [ 'C._..
LAVATORY
ROOF DRAIN
-
SHOWERSTALL ®r— . I_ - 1-----'1 tI=_ ti : r [ �(`II _ I
L-_- ►. -=1,____, 1,�___ f_-I - Ic.- r- c ,ram _
TOILETEIMOP SINK M� =il ; -, — _,
TOILET _ '7-''1.:- 1._., I_=_v_ 1L_..-7
URINAL I :'I L-._.__-1 -�-. •L TI__ L _ r--IL._:_I� :_...,IL
WASHING MACHINE CONNECTION (�- 'I--� I _-. .�`�1 _'E I -- P—'I _-I
WATER HEATER ALL TYPES MI _ I. _:=L�::-:_I7_�_.'I. ._ . •I._ . ..- ._._C --
WATER PIP_,G �- 1 - -� -
OTHER WA _- ' MAMINNI®®®®I ._ _ ®® -
- - Mr__ 1 1 ,I
�
I- `I
1 =_j- -'µ" _' .,z INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO L CI--
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E OTHERTYPE OF INDEMNITY 1 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 D
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are t 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 lance with all Pertinent
s���ion of he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME I STEPHEN A.WINSLOW_ �I LICENSE#112298 _I- SIGNATURE
MPD JP®
CORPORATIONW# 3281C PARTNERSHIP®#,_ LLC # i
COMPANY NAME EF WINSLOW PLUMBING&HEATING f ADDRESS 8 REARDON CIRCLE T -___--- - _— -1
CITY SOUTH YARMOUTH r STATE MA - ZIP 02664 J TEL 508-394-7778
FAX 502394-8256 ` CELL NIA EMAIL accountspayable@efwinslow.com
A
The Commonwealth of
De�� 1. Department Massachusetts
p tment of.Industrial Accidents
—*slaj
� 1 Congress Street,Suite 100
Boston,MA 02114-2017
N.
v---_--
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH TNT,PERMITTING AUTHORITY.A licant Information
Please Print Le ibl
Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH,MA 02664, Phone#:508-394-7778
Are you an employer?Check the appropriate box: Business Type(required):
1.❑✓ I am a employer with '7 0 employees(full and/ 5. 0 Retail
or part-time).* 6. DRestaurant/Bar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no
7. 0 Office and/or Sales(incl,real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. ❑Non-profit
3.0 We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152,§1(4),and we have
no employees.[No workers'comp.insurance required]* 10.0 Manufacturing
4.❑ We are a non-profit organization,staffed by volunteers, 11.®Health Care
with no employees.[No workers'comp,insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL,MA 02467
Policy#or Self-ins.Lic.#1821A
Expiration
Attach a copy of the workers'compensation policy declaration page(showing the policy Date:
expiration date).
Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
fine 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
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification_
I do hereby cer , r the a his and enalties o perjury that the information provided above is true and correct.
Si nature: �._-,� 19 -°-�
• `.-..,..p - _. Date: 1 _ (3 1 I f
Phone#:508-394-7778 •
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.Licensing Board 5.Selectmen's Office
6.Other
Contact Person:
Phone#:
www.mass.govldia