HomeMy WebLinkAboutBLDP-19-000037 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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my(_iw CITY __.`. ��� MA DATE /,�'i/u PERMIT# I�P/�"W 7
JOBSITE ADDRESS LW k c� omit. OWNER'S NAME << " JL c �
POWNER ADDRESS - _ _-. _ _ TEL, US 3 5' .Lail' FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:I I PLANS SUBMITTED: YES Q NOD
FIXTURES 7 FLOOR—I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1� yl
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM __ f j f J_
DEDICATED GAS/OIL/SAND SYSTEM ---1, f - 11
DEDICATED GREASE SYSTEM �J —�
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM —••I—. "— r----'r
DISHWASHER It_ -]t~—L ,_1 I' J
DRINKING FOUNTAIN li—F-1 I!, l_ L
FOOD DISPOSER j— �����
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FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR) _ Ir ,,
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KITCHEN SINK L ._.v-II i'
LAVATORY ----1 (--1 L
ROOF DRAIN MI MN MI - MI MINI"
SHOWER STALL I II MINIk — `
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SERVICE/MOP SINK ( i, `
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TOILET I MI' NE -'
URINAL Y _ ._J U 1
MACHINEWASHING WATER H ATERALL TYPESOJ I CTION _ , _ I
WATER PIPING r _ILL — IIII L
OTHER -r '
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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 Lj O
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY D BOND 0
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. It
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 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 co lance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A.WINSLOW I LICENSE# 12298 SIGNATURE
MPO JP❑ CORPORATION El# 3281C PARTNERSHIP®# LLCO#
COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY LSOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A I EMAIL accountspayable@efwinslow.com
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Department of Industrial Accidents
„ t Office of Investigations .
=,i��- 600 Washington Street `Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ) Please Print Legibly
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Name(Business/Organization/Individual): E • W+,^S,• O ni Q(k)v,,, tokvicl . tc ✓vc, c .) Iel(
Address: v (JX
City/State/Zip: SOQ tAP- Phone#: '50S- 394-1-1'7
Are you an employer?Check the appropriate box: Type of project(required):
I 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
:.El am a sole proprietor or partner- listed on the attached sheet. $ 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
❑ I 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' 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.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation.
tsurance Company Name: A+(YUw' C'\v c✓� l 1 f oak rl(�„ C eL ,evl.)
Dlicy#or Self-ins.Lic.#: \ $ cZ I . 1 Expiration Date: (—I '• �a('U i9
AD Site Address: 3 r\cvl it Cts.e3AN4 l 11 City/State/Zip: O,)"-t b
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
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
ivestigationst6f`the DIA for insura overage verif a on.
do hereby certify un e te ains an penalties o p jury that the information provided above is true and correct.
natu�c� Date: 11 3 i I aGI?
hone#: st `j`j 777g
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#: