HomeMy WebLinkAboutBLDP-18-005237 , t'• iVMASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
= =ra CITY! r�;d. I MA DATE�3_z -/�' PERMIT#
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JOBSITE ADDRESS G� rtto ,, Adi e / [= OWNERS NAME ,1 ;L L . �_ �°I r7
OWNER ADDRESS YTELZ2
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL U RESIDENTIA !.'4
PRINT
CLEARLY NEW:D RENOVATION:1: REPLACEMENT:] PLANS-SUBMITTED:YES NO1
FIXTURES 1. FLOOR--1. . BSM .1 2 3 4 5 6 7 8 9 10 11 12 13 114
BATHTUB {f-_71- i -:[771--.---=r:.....il.:.71 1:__t. I I(=.:-� -73
CROSS CONNECTION DEVICE ILL.-, !f-,� ',r. �r.--_.i.l..._Al._.._?I:,�.,.•:_7 ..707.-D-=l - -;
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DEDICATED SPECIAL WASTE SYSTEM. [�.,;;'P 1I 17.7�=,-.1 I :,_,•il_ s`I_ a: t� I i='®®
DEDICATED GASIOIIJSAND SYSTEM i__r��� ;(- i_r•+l•.. .+C•.• IL.-•• I• .•t ..,_ It. '�'®®
DEDICATED GREASE SYSTEM I`T' 1 jr- 11 IL -::#1__._i__-y-ri� 1 r -T `®
DEDICATED'GRAYWATERSYSTEM G-ar is .11 _ (L.;_:3I-__,SI,_-,.h1=—`1 C.:-{i- iETrT
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• DEDICATED WATER RECYCLE SYSTEM h__--,Ii�` I L_ [�_ ::1-Ti_ 1I- ::I Ir- -_3I:,-_t: 1----�} �`i= ; '
DISHWASHER _ :.1 1;. •:r. �,_==1C__ " .. i t -i�i( _L
DRINKING FOUNTAIN L=-._I, i- `1.•_,._ r-..I, 11._-•.:.?I•• L!"I ::r r-=-r W
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FOOD DISPOSER h, L:.._.!r_T`,r=I ;::...,lT 'r 'I-. `I .,_III. . 'IrIr•--'
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FLOOR I AREA DRAIN r---t ?1= tl___ 1 L. ....17:„ .:�1, ,- ,`sr LP:
INTERCEPTOR INTERIOR - I—•:i=SC-'•1.i = ,1,:.•.:-L-- I rid` L-` "
KITCHEN SINK �_ rI -�I fir_- rl fl; i
LAVATORY I---,iL �L
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ROOF DRAIN L.__ 11r • ,;r--I,7_ it . I.,- L--.;.,. . `I----.-lF CT•1 .
SHOWER STALL =,s_._..IL- ..... .._,(—�=iL.:_ _ - ...
' SERVICEIMOPSINK i -_1� [- --Tl1, -= f ) s� 1 -i��
TOILET 1- hL ir.. ..+r- ?LPL-.-..il-•_.-.sib',L_._''r-., .E-_ 7 s._i
URINAL - L, -1L I Il C,TC E .aL l _ WM
WASHING MACHINE CONNECTION I. ....,.11 - 11. .'I_........ _ . II_ _'I�P'II_ 6 ` t• iJL_.LI ...---- V
WATER HEATER ALL TYPES [-1I.:� -t. 1L _ll. II.. . p.,_'�I. . l,._ .!17—. ........ =r,�`
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WATER PIPING _ c = 1r" 1 it ;1. .. r1• �,1.::117 ,. C. �` ...:.1 ',
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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 D
IF YOU CHECKED YES,PLEASE INDICATE THE TYPp OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY El OTHER TYPE OF INDEMNITY a BOND U-••
OWNER'S INSURANCE WAIVER:lam 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 DI AGENT U _
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 nd 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 comp ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME',STEPHENA.WiNSLOW 1 LICENSE# 12298 r SIGNATURE
MCI JPD CORP ORATION U#13281C iPARTNERSHIPD#t 1LLCD#
COMPANY NAME EF WINSLOW PLUMBING&HEATING.i ADDRESS 18 REARDON CIRCLE
CiTY TH YARMOUTH r_ 1 STATE MA I ZIP 02664 • TEL 508-394-7778 i Li?l
FAX 508 394 8256 CELL NIA EMAIL accountsp�able@efy�inslow com - -�
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orknrr�9 Co >�Qi�sat®n Ti>'s,�nL��nrtere www.massogov/dits
ol��ir�/�®y��n���®��trp®1� �itt1Pactorrs/Fflterytrrflcia,u,�fl�l�fl�er�
Please Mat Le I
(Business/Organization/Individual): ,C I. pri5t OW
tate/Zip: a_.A cry
es Mi Phone#:
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an employer?Check the appropriate box:
n a employer with 70 _ ¢ Type of project(required):
�] I am a general contactor and I
ployees(full and/or part-time):* have hired the sub-contractors 6. ❑New construction
n a sole proprietor or partner- listed on the attached sheet.? 7• ❑Remodeling
and have no employees These sub-contractors have g,
El:king for me in any capacity. workers'comp.insurance, Demolition
>workers'comp,insurance 5. [ We are a corporation and its 9• C Building addition
aired.] •officers have exercised their 10 C Electrical repairs or additions
a a homeowner doing all work . right of exemption per MGL I1,0 plumbing repairs or additions
self,[No workers'comp.
P c,152,§1(4)}and we have no 12,_Roof repairs
trance required.]f employees.[No workers'
comp,insurance required.] 13.[Other
nt that checks box#1 must also fill out the section below showing their workers'compensation policy information,
-s who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
hat check this box must attached an additional sheet showing the name of the sub-contractors.and their workers'comp,policy information.
iployer that is providing workers'compensation insurance for my employees, .below is the policy and job site
n.
J A: mN -----(`ompany ZJC (1 L t.f
Self.ins,Lie.#: ` '
(�' • Expiration Date: �-[ •— �`�.b}'�
[dress:�,� �C;rtrvv1Ct7`i w-ev[i �
I, 3\e:3 4 (" I1 City/State/Zip: O 4 GG 7)py of the workers'compensation policy declaration page(showing the policy number and expiration date).
ecure coverage as required under Section,25A ofMGL o.152 can lead to the imposition of criminal penalties of a
1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORT(ORDER and a fine
0.00 a da against the violator. Be advised t, t a copy of this statement may be forwarded to the Office of
ns rthe DIA for insura o overage veri Gallon.
certify uncle .e sins an4penalties of pe jury that the information provided above is true and correct. '
L._ / A
1 Date: [ _1:3 i ) 9,01
N.'.;CNI' 777g
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we only. Do not write in this area,to be completed by eity or town official.
`own.:
Permit/Llcense# • i
uthority(circle one): •
of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector
'erson:
Phone#: