HomeMy WebLinkAboutBLDP-18-002789 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS 7/ OWNER'S NAME 11101MPAIM:' 1
p OWNER ADDRESS I - T E L NIMSTIfilia FAX
`" TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL
PRINT
CLEARLY NEW:L1 RENOVATION:1=1 REPLACEMENT:Q PLANS SUBMITTED: YES El NOI
`�,, FIXTURES 1. FLOOR-I BSM •1 2 3 4 5 6 7 8 9 10 =®® 14
BATHTUB . ' _ �' 1 �IIIMOM
CROSS CONNECTION DEVICEDEDICATED SPECIAL WASTE SYSTEM MgingliVierOMMINIMMISOKIIIMattrill
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DEDICATED GAREASE SYSTTEMSTEM �__; �_ � �
DEDICATED•GRAY WATER SYSTEM ,_ I tl�_ _ I� mi_
DEDICATED WATER RECYCLE SYSTEM �r �r � - _ '
DISHWASHER r _�. ___, _.� in ':IOi
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DRINKING FOUNTAIN A � M _ IM
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FOOD DISPOSER 1 - +I,� !�
FLOOR!AREA DRAIN IL I IPIIlIII'-Mll.l-MlMI----iii1-
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KITCHEN SINK tm� mgNg
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ROOF DRAIN
SHOWER STALL lR'. :
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TOILET ringlArmiNIXIS. .-URINALRp C"' �.timPl
. . 'WASHING MACHINE CONNECTION t _.,_„ � �,�„',� �� ,�__ : -.!' � —_ I�
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WATER HEATER ALL TYPES i' _ •_ ,__ 'M
WATER PIPING r , .` r• •
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OTHER ........._.. ., � (. __._ � ��� - _ ���M� - -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ed NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY I OTHER TYPE OF INDEMNITY l 1 BOND D-
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 ® AGENT 0 .
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are tr 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 co ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
.41 _ L ��-�.1C.--4'.-Ci_ .
PLUMBER'S NAME STEPHEN A.WINSLOW !LICENSE# 12298 SIGNATURE
MPU JP El CORPORATION El# 3281C IPARTNERSHIP0# LLCD#
COMPANY NAME if WINSLOW PLUMBING&HEATING ;ADDRESS 8 REARDON CIRCLE ]
CITY SOUTH YARMOUTH I STATE MA ZII? 02664 TEL 508-394-7778
FAX 1508-394-8256 4 CELL N/ EMAIL accountspayable@efwinslow.com
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Department of dndustrual Alcctaenes
,,_:=6_ l Office of Investigations
_171111=5 600 Washington Street
5`-it ;:4Boston,MA 02111 •
'., www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information 1, Please Print Legibly
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Name(Business/Orggttanization/Individual):E'C.•W,�SlQv� Q(Vsn6I,✓te' .t1<..:x\ c vic
Address: ' l�Pt� C itrR— o
City/State/Zip: 'Soo kh h^cv.'k NPr Phone#: 450S-3IH-'MC,/
Are you an employer?Check the appropriate box: Type of project(required):
AI am a employer with "y0 4. 0 I am a general contractor and I 6. 0 New construction
employees full and/or part-time).* have hired the sub-contractors
;.0 I am a sole proprietor or partner-( p - listed on the attached sheet.I 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. Li We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL 11.0 Plumbing repairs or additions
❑I ys a.[No workers'e doing all work c g152,§1(4),and we have no 12.0 Roof repairs
myself.[No comp. '°
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
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.
-m an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site
formation. I (`
isurance Company Name: /�Y_ (r1 YO-•.s C s-)kJC1-A , ,1'(Ft&''t Ce- \ tliseY-Vi`f
olicy#or Self-ins.Lic.it: 1'3 Al A • Expiration Date: t,-[- aoi--)
ib SiteAddress: 3 rkanw,ee"1 Aote) C S IA11' City/State/Zip: b,)W 67
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
t•up to$250.00 a da a:ainst the violator. Be advised t at a copy of this statement maybe forwarded to the Office of
tvestigations• the DIA for insurat3etrroverage veri lion.
do hereby certify unns an (penalties o pe jury that the information provided above is true and correct.
pnatt /I . Date: ( 3ll9.Okti
hone#: .Sl>9.•3`I`1.777g (t
Official use only.Do not write in this area,to be completed by city or town official
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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#: