HomeMy WebLinkAboutBLDP-17-001403 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
AVECITY / IMOLA_ MA DATE q -I 5-Ito PERMIT#/ )/,7 a,
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JOBSITE ADDRESS 82 Poi nsepx-ci o_ br U� OWNER'S NAME ri 10 S0._
OWNER ADDRESS .8 Acres Rc� (n t (Ford rim TEL 5O8- d`'f86B FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL .
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _ _
CROSS CONNECTION DEVICE I _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM r
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER 1
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES , NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY ❑ BOND ❑
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 ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME lr?"Ian HOJ n0117,3111, LICENSE# /5'755. SIGNATURE
MP JP❑ CORPORATION❑# PARTNERSHIP LI� .# LLC❑##_
COMPANY NAME !'IU. WowsrA,' IYl ee han i eed L -d ADDRESS 417, l i'1 F� 1-1 n4 Nouse. Road
CITY S uffi C h .t-hQrn STATE inn ZIP 02.1,5 9 TEL 508 430 41-374
FAX 174 '23-1 - do8(2 CELL EMAIL km oi1(in Oak 6 yQ.hco , eon')
•
•�—1 T I
TJze Commonwealth of Massachusetts
I. ` ` ri Department of Inclidtrial Accidents
_ _E? 1,_am a ... Office of Invesizgatians-
;1! =� 600 Washington•S'treet
www.rnass.gov/dia •
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Info rmation • - - Please'_Please'Print Legibly
Name(Business/Organization/fndivjdual): KCt1 t it o tt);III : fl' e h a n i 0.lll� Lfd •
Address: L4 12, I.1"Io 0-1 qp tip use cld .
City/State/Zip: .3) (linfh m 0)A `)21c5(1 Phone#: JI—3/- -- -1-1-230_., -37
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 4. 0 I am a general cons actor and I 6. Q New construction
employees (full and/or part-time).* have hired the sub-contractois
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These actors have 8. D Demolition
working for me in any capacity employees and have workers', 9- ❑Building addition
[No workers' comp.insurance comp.inst?Zanee$
required.] 5. C1 We are a corporation and its 10.0 Electrical repairs•or additions
•
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself.[No workers' comp, right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §I(4),and we have no
employees.[No WO1kL Ls' 13.0 Other
. comp.insurance required.]
"Any applicant that checks box tl mast also fII7 out the section below showing their work ns'mmp=sitina policy information.
t Homeowners who submit this affidavit indicating they ace doing all wort and then hire outside contraetoa must submit'a new affidavit indicating such.
$Contractna that check this.box most attacked an additional sheet chewing the name of the sub-contractors and state whether cr,not those entities have
emplayces. Tithe sub-contractors have employees,they mast provide their wortess'camp.policy number. •
I am an employer that is providing workers'compensation aunrancefor my employees. Below is the policy and job site
information.
Insurance Company Name: A5 Der)ai-pd •El11Piol,f r 1 In Su ro no e
Policy#or Self-ins.Lic.#: f,(,%CIC.rj0Q�j 0 I 3 3-4 2i)1 /A Expiration Date: 14-13_C 7-
Job Site Address: . City/Statc/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and 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 S250.00 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 certify under the pants andpennl&s of perjury that the information provided above is true and correct
Sim: Date:
Phone#: .8 - '-"f0 V 043 7'l •
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.ElectricaI Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: -- /