HomeMy WebLinkAboutBLDP-17-006586 gi-4P /7-oo&S$G
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY + /l�*i ;1 t L- Y- _ MA DATE
g-= � E` i ( `/ 17 PERMIT#��
JOBSITE ADDRESS C;l -7 1 A n, c. t. -i OWNER'S NAME ell&fi , 6-k_k“.4
T OWNER ADDRESS I +[� IT-1 ���f�� �}.�
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TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL D RESIDENTIAL(a-
PRINT
CLEARLY NEW:L1 RENOVATION:0 REPLACEMENT:D-" PLANS SUBMITTED: YES[ NOW"
\O FIXTURES Z FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _____C^ri ,,�, I` ' _`L 1. ..C ;I.—`( . . _I--1_ �7.71L-�. .
CROSS CONNE:CTIONDEVICE '1 ^'I�7(_ „_,yr-jr..._ iT . fl r r 1l__._ll -rr i r ir--
DEDICATED SPECIAL WASTE SYSTEM 1_._. �i--1 (�- ::37 _,1 ,1 Iw___,A JI .11 _..JE77, `(_�.._j
DEDICATED GASIOIUSAND SYSTEM I .. I, rl- ` _�. RI ) 1 I--� . - ,fl_—`( i s
DEDICATED GREASE SYSTEM [.__s_1_ .I. . .I- i.L:_ ..11_. ... ._r.._ rtI., _..t1.• - -II--- -- --k1-----E--C—
DEDICATED GRAY WATER SYSTEM ,_y _I .,F r ;I ( _� j }� �`-i( ,1�-,r-{(i
DEDICATED WATER RECYCLE SYSTEM (,___ri1 __-_.'E~(_-[�_11 . .,a(^__�_.. ,'� _,V t�„„_,__-;I�.__ 'i . [ 1 _
1 DISHWASHER I _ 1 --I : , L. I := sl,_..1._;1 .11 L._:_ `r•-- l .....`i ,l_ - r_
DRINKING FOUNTAIN r --r yl--� 1 -1�-j�-�i�l (- ( ._ 11--,r� __i'
i I FOOD DISPOSER I r1 F. •I_. • _(F--iI ':17 (~ 1 . I :_1. . '1�-I x
FLOOR/AREA DRAIN 1?-.. rr. .._'L._� ( .._ 11 � h ( i- I {------r--
1 II INTERCEPTOR(INTERIOR) I--._II ..1�_ I _._. il-:'r-1r--(_,_ I: ; r- r-l:_ 1zn,`
zq KITCHEN SINK I __ 1. - -RI_ - 'r-- [-:-11-7 r i1~ 1 . �._-_c1 .1 'r 1
LAVATORY I^ Tr- k _I----I .. Iflhi..: -i ,-f 'I---.. 'I _ (----l:r-- �i`
�1 ROOF DRAIN I 11 1�-1 I it if -1 ( _•`,r--r I if: i—_
SHOWER STALL ...,-I� li q(_ i� +��1 ar--('-1�-, _ �.__
SERVICE I MOP SINK _ 1L �-L�,..1 J J1 .. _!=.3 !i _ ,L : _ 17.. r _+r-i
1$, TOILET 1, _.._1 _ ( + . '1_ _iL „i1 1_ t I _ ��. (_ ->.._
URINAL 1_1r 'I i,-w 'Li P � --j- -T. .. ,I-__-�-1I 1_�_
WASHING MACH NE CONNECTION I it s-!(-- 11_ .. !I II 'r-7, 11 1 T_7.77 i
WATER HEATER ALL TYPES -j_il.. . _.I L __I_ . 'I- .. .-1�_,., 'tl. . ;!I:.__:r „s :- . __,[.. --- C.
WATER PIPING ,.-�-1r-✓7--- lr 71 .._,. ;1 , . . i. . '1 _( 'f1 :1 .. i1.. ,1---: .:
OTHER • - -_4 .._1r--l—:r---,I---D --1i (-�1 _. I. 1 . r-r1 1-
L .�7 1 i I . I_-- I— 11-'1 - 1___=- 1_— ,I -► •f-1
T_� T— —_tt:„ �1( I_._ `i_ r'_ ir `_Il r-_' 'I_. 'l _J=;1�.�i-:,f�_
KK, INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO
\\\\\\ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E1 OTHER TYPE OF INDEMNITY Li BOND El
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 0 AGENT 01
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 Pertinentprovislon of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / !, 4 ��� t
PLUMBER'S NAME STEPH __EN A.WINSLOW I LICENSE# 12298 = i ��SIGNATURE
MP El JP Li CORPORATION Ell# 3281C I PARTNERSHI P Er#r_ LLC[21#L
COMPANY NAME EF WINSLOW PLUMBING&HEATING i ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH —IJ STATE MA-I ZIP 02664 __ _ __ -1TEL 508-394-7778
FAX 508-394-8256 j CELL N/A _1 EMAIL accounts ayable@efwinslow.com _ s �yW _1
_ Department of IndustrialAccutenis
1-9—�i)h l Office of Investigations
e=_i51111=
•T. 600 Washington Street
1:4= • Boston,MA 02111
-•. 30 www.mass.gov/dia •
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information vl
1 ' Please Print Legibly
•
Name(Business/Organization/Individual):E,C.\�rrr\5 QI OW inw c S- f.0.1-,..1 ce•�ha'-it.
Address: �j r.IP'-- d
City/State/Zip: SoAv\ kitcfw,n.-1.-+ MPS Phone#: '50b-3cM-1'77S1
Are you an employer?Check the appropriate box: Type of project(required):
,AI am a employer with -70 4. 0 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.t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp.insurance 5. ❑We are a corporation and its 10.0Electrical repairs or additions
required.] officers have exercised their
I.❑I am'a homeowner doing all workrightexemption of exem tion per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),and we have no 12.0 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.
:o)ntmctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
dm an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site 1
ttt brmation. /�
tsurance Company Name:_Arrl•.,J f si kJ of l .S.TIN,(Gt n f 2 kyv)
olicy#or Self-ins.Lic.#: I 5 oZ I A- Expiration Date: (—[— au-7
lb Site Address: 3 4r\anw-em•-t1"h Ad--ey CF2;3)4 M City/State/Zip: Gal in 7
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 da a:ainst the violator. Be advised t t at a copy of this statement may be forwarded to the Office of
tvestigations• the DIA for insurance 7overage verii on. (
do hereby certify u re ins an%penalties o rug that the information provided above is true and correct.
i• atule': _1 r.. Date: tot I bL0[+''
hone#: .S1)°.3I4-7 77d
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#: