HomeMy WebLinkAboutBLDP-17-001178 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
M "- _T _ CITY , i MA DATE .. it.,i PERMIT#J3J-1)1-/7_V/114`
c� JOBSITE ADDRESS /5 /U(ii h 0iI✓l r,� . , OWNER'S NAME -- i-ff-,,--,
pOWNER ADDRESS 1_ _ ✓Y1 J TEL ei'//. ot.)�?`r.,FAX `_
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 1.j
PRINT
CLEARLY NEW:LI RENOVATION:L REPLACEMENT:[ PLANS SUBMITTED: YES[ NOW-
FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I —i(-T I ;� i ' "r:_i t. : -- '17,. r_.- l-r . .
CROSS CONNECTION DEVICE 19,,,,r°I E T .{ E . _ il� ;i _,I 1_. ((
DEDICATED SPECIAL WASTE SYSTEM L__ ;771 I I" r-,f I I 1 _._,. I— ;L= _ j_ ,I _ ( T4
DEDICATED GAS/OIUSAND SYSTEM - I... _(--1- 7'�1„ ..if ;(— ~f (— (--r I _ . 1—I_ (-
DEDICATED GREASE SYSTEM [,.T_ I I I I I f ._iI (1 j 711 __ _ .,t7...E_TEtt
`� DEDICATED'GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM r„_•,iP-F :(T�,�,= i�II ,I _;. 1 '�� ;I )I .11�.?C— ��-_
DISHWASHER • I—.v-�II I ._. f7 _sr:,._._I'. .-,- I,.. _,__�,... 1 '1 1�-1_- -. L
DRINKING FOUNTAIN r..- _<i i1_ [-Tr-_Ir- '._T---_ ?1--'(- :l :.1 :F.__ !1— :.1._____
FOOD DISPOSER I,E,� r-_ ;r...._ r•- ..x.
FLOOR I AREA DRAIN I . ..1:: ,'L.._- L_:.-7__.L l_:__.: _ 1.:._ _.:,ITT(-_ ..'f . :117-7.1---1- --r—
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INTERCEPTOR(INTERIOR) I__._'l l_: ,.1�--f 'h .,.1I ., I -II ... _ �71 .7 I. ; ,_-_, .1- 1___• `
KITCHEN SINK I___ '1 .. .II— 'i__T-.1-711._. __T . _'',I -I- __.1- 1 _..' .i 1
LAVATORY 17:- ( it —_I---_-`I. i1_,- L:- 71. ._,`;r i-__._:I-71.--__J-7-----jr `
_ �,.,.,�.I .I F_T-11 __ 1 —IL__.":1 —!,fir.----1—•—F-7[_7—[
ROOF DRAIN I _
SHOWER STALL L1I .,11 �i, ,r ±- „IF__,1�'i—i�-1 11 -'1 �I.--'� f
SERVICE/MOP SINK - „_11- , : ,-.-Tj. _IL ,. ._� I�� -1,.,. I. _[ .__.[-;1„
_TOILET -,�:.:11...T:. —,1. _. 'I I i1.__,_,.�L 11. L ''[ 'i __ 1- - t�-
_URINAL { Ir r if `�- :P.�I[..-__it '�;1 -- [.T--1:1�-:__ ;1 I�--T
WASHING MACHINE CONNECTION r 11- �_Ir-- 11- .. 11 1 ?!----7-.---- !I._ 'h 1____.
WATER HEATER ALL TYPES .;,�_iI -. _71_ . -177( .. ..1[7.711.. 1 __ ._'r .L_____`1 ._ -1. ___ Er
WATER PIPING 1111_..-i—,F __I[--Iz__ .JI . . . 11 '1-. . . 1-7 '1 ;1- .. 1^ r
OTHER r_.. _ __- _ 11 1—;1� E ._II- 1 I. ,1 TT l_ .[ .
_' .1_ i 1. 'F 1 1 I
r ..._s.— ,,,,,,,___,___2�z i1 I 1`— _,r— ,r_— . II L�_-r-1— .1---.[--J__I-_I 1—_____
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0+ NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY El OTHER TYPE OF INDEMNITY® 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.
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 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 compiil nnce withh all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `' rya �.
PLUMBER'S NAME STEN A.WINSLOW a ____ya 1 LICENSE# 12298 L EPH SIGNATURE
MPO JPD CORPORATION:# 3281C i PARTNERSHIP LI#LLLCLI#
COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE I
CITY LOUTH YARMOUTH _---<1 STATE MA I ZIP 02664 TEL 508294-7778 �__-..-_
FAX 508-39 4-8256 i CELL NIA_ ___1 EMAIL baccountspayable efwinslow.com _ ..__ 1
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___. Department of Industrial/Iccraenes
c_,-,fit=_Vt Office of Investigations
_;chit-a 600 Washington Street
2111 f='4 Boston,MA 02111
�'^,:, r' www.mass.gov/dia •
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
pplicant Information C ` Please(� Print Legibly
lame(Business/Organization/Individual):l-•c•\,�,A.s 1 ow Q(V�6�✓tcct L k4 o ':^q, \u-�1'„c.
ddress: P\pe an Cltr�tz- a
Dity/State/Zip: Soo k \ Ycr-w o,.kn CMPr Phone#: `500-3c14-177t1 •
ire you an employer?Check the appropriate box: Type of project(required):
,( I 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 Remodeling
El am a sole proprietor or partner- listed on the attached sheet.t Elg
ship and have no employees These sub-contractors have 8. 0 Demolition
working forme in any capacity. workers'comp.insurance. 9, ❑Building addition
[No workers'comp.insurance 5.0 We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
per❑I am a homeowner doing all work rightp
of exemption 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.
:ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
im an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site `
!formation. �
]
tsurance Company Name: fYY •� , r C� �olicy#or Self-ins.Lic.#: \$a l A. • Expiration Date: 1—l` an17
Ib Site Address: 3 nAori wP o-(1-h -e/ C • 1it1' l';-;\\ City/State/Zip: 0„),-1(6 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 i at a copy of this statement maybe forwarded to the Office of
tvestigations r the DIA for insuratpee-overage veri a on. /
do hereby certify un'• e gains an;penalties o jury that the information provided above is true and correct.
i atu4
S'' Ai f,_AL._ Date: ( . 1 b101f'
hone#: 5.)C35`l,7 77g
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#: