HomeMy WebLinkAboutBLDP-19-000832 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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t-4 CITY YelinvV '1^ _r.__ __ .____ MA DATE cl i1 L1s PERMIT#4-49P4/ o,/.L
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M B IT�7.61 ADDRESS gb.ltt(�bIGNJO(?d.j( IAf MO✓}'(tfr OWNER'S NAME J+ 1IGh_....F
POWNER ADDRESS gu,M _ __ _ _ _ _ , TEL128367 citlii 6 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL E
PRINT
CLEARLY NEW:® RENOVATION:El REPLACEMENT:0/ PLANS SUBMITTED: YES 0 NO0
FIXTURES 1 FLOOR-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB - - I l
CROSS CONNECTION DEVICE V I � ] l I�
DEDICATED SPECIAL WASTE SYSTEM II U . II y 1
DEDICATED GAS/OIUSAND SYSTEM [ 1 � ] „ � j
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM I^— d
DEDICATED WATER RECYCLE SYSTEM ___1 I II I, 1 -t I
DISHWASHER
DRINKING FOUNTAIN II I I I II I I
FOOD DISPOSER I I I �1 �r
FLOOR/AREA DRAININ=
INTERCEPTOR(INTERIOR) , __ 1 1 I Ii ' 11 I I, 1
KITCHEN SINK 7 I I
I
LAVATORY TROOF DRAIN _- CI 1 1 :
SHOWER STALL `' i
SERVICE/MOP SINK1111' 11 9 Ma' '
TOILET
I
URINAL I III•I I A 1I 1 I
WASHING MACHINE CONNECTION J . tr _I J )j 11 1 1
WATER HEATER ALL TYPES p I t l
WATER PIPING U 1 l II _ ' II l U
OTHER 5.imIt I U 11 I ' 1 (I
Id i, 1 1 f 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 0 NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 BOND El
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 El AGENT El
SIGNATURE OF OWNER OR AGENT
�n I hereby certify that all of the details and information I have submitted or entered regarding this application are t nd accurate to the best of my knowledge
a • and that all plumbing work and installations performed under the permit issued for this application will be in corn I' nce with all Pertinent provision of the
-4-, Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
`, PLUMBER'S NAME STEPHEN A.WINSLOW I LICENSE# 12298
_.... SIG TURE
\INMPO ,)P❑ CORPORATIONO# 3281C IPARTNERSHIPQ#I ILLCQ#
7 COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
'� CITY SOUTH YARMOUTH STATE I MA I ZIP 02664 TEL 508-394-7778 _
-s FAX 1508-394-8256 J CELL I N/A 1 EMAIL accountspayable@efwinslow.com
1 A 66{. O�V 666666IM IYL6666"VJ Ars 66JJ661.0.11.JH.66J
Department of Industrial Accidents
„�lio►_ft
Office of Investigations
1' 600 Washington Street
k. :.1l1:
't`-�- Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information f i /� Please Print Legibly
Name(Business/Organization/Individual): E‘C• Ow Y(V,A,k6 kvic . �-�ec_\ Ce.) l,rl(
Address: Keegan es,rckQ-
City/State/Zip: So -v*\ cry-T..,,rk'-' NtPc Phone#: GjUa- 394-11?�d
Are you an employer?Check the appropriate box: Type of project(required):
,., `am a employer with 70 4. ❑ 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.1 7 ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for 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.❑Electrical repairs or additions
❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.❑ Other,
thy applicant that checks box#1 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 hire outside contractors must submit a new 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.
am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation.
isurance Company Name: ArY J Mike-A l_ SOrCA.n(..Q. CWs/set-V1'1
olicy#or Self-ins.Lic.#: 1 $a i A Expiration Date: (-1 - aO9
)b Site Address:a3 G rw cif v•-ec,--11'1-, f 1 C k i4 IACII City/State/Zip: O014(e 7
ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ailure 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
[up to$250.00 a da against the violator. Be advised t i at a copy of this statement may be forwarded to the Office of
tvestigations the DIA for insura •- ,overage verif .r on.
do hereby certify unt e le ains an penalties o p•jury that the information provided above is true and correct.
ignatuu'es Date: l al 3 i 1 a017
hone#: 51)%:3 i- - 7 7'7g
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#: