HomeMy WebLinkAboutBLDP-19-001480 . \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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'+ -�'Zi ' CITY _M[LYjCCtT it sr) MA DATE 3'/30,/8 PERMIT# /"'/�'0171�
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JOBSITE ADDRESS AO Lam/ ///9-14 J Gti,4 _ OWNERS NAME ) (LOW, -
POWNER ADDRESS .51in --- ___ Hv_.__ _„ _ -- .,r_ m. TEL 5.-a ilg'-F�5 5-- FAX _ _ _ _
TYPE OR OCCUPANCY TYPE COMMERCIAL ED EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:__,I RENOVATION:Ti REPLACEMENT:1 vi PLANS SUBMITTED: YES Li NOLLf
FIXTURES 7 FLOOR—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ! _ _� I
CROSS CONNECTION DEVICE _ ----1 �F-
DEDICATED SPECIAL WASTE SYSTEM ( I
DEDICATED GAS/OIL/SAND SYSTEM - • _.
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM JL (,
DEDICATED WATER RECYCLE SYSTEM 11
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DISHWASHER �..... _ �..
DRINKING FOUNTAIN _
--i r--
FOOD DISPOSER I
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORYv
ROOF DRAIN 1; 17--
SHOWER STALL , 11 , jr _11__ l— ,1____,SERVICE/MOP SINK ��� -17 1 _
TOILET JL �i �I L
URINAL _ .1 1 ._�1 1-11-
WASHING MACHINE CONNECTION �i.
WATER HEATER ALL TYPES �r If-
WATER 11 a[ �
PIPING
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OTHER b _ __._ -_ v .. _._. I I' 1 'r -
do I
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INSURANCECP COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ] NO J
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E OTHER TYPE OF INDEMNITY El BOND ri
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 Ti AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are if and accurate to the best of my knowledge
d0 and that all plumbing work and installations performed under the permit issued for this application will be in co�'r.liance with all Pertinent provision of the
�' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. A`;_ . , aet
PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 - SIGNATURE
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MPQ JP CORPORATION0# 3281C _PARTNERSHIP®# ILLCD#
COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL NIA EMAIL accountspayable@efwinslow.com
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P .2\ 1il/6/6Y96t/Y6 IY8.K6696 VJ 1I866JJ66L0666J6.66J
-•_ Department of Industrial Accidents
•�. 1, Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): E•F•1,,v+,r„tG.A, 0U".t0kvZc, .e Iel(
a Address: QPe co d
City/State/Zip: So NP Phone #: '5O - 9-1 T1'I
Are you an employer?Check the appropriate box: Type of project(required):
ArI 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./ 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 10.0 Electrical repairs or additions
❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 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.] 13.0 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: AY-TO CA•i t;OA l f uvrA el(.i .. C etetiki
olicy#or Self-ins.Lic.#: $a i Expiration Date: -] - ar✓i9
)1)Site Address:;)3 Grvvvvcv)vt-ec Jrh A-0-e C,,23 'I' r'1)11 City/State/Zip: O, L4 to 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
F up to$250.00 a day against the violator. Be advised t at a copy of this statement may be forwarded to the Office of
tvestigationse DIA for insura overage verif a on.
do hereby certify un e ze ains an penalties o pe jury that the information provided above is true and correct.
ignat& Date: (1) 3 i 1 aoki
hone#: Stg - 7?7X
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#: