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Home My WebLink AboutBLDP-16-004956 C WN z —ii 1 �,t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,r-. ci a' ® CITY yq rr - f I t I MA DATE Noq( 6 PERMIT# 6 19P-/6' 'o'1g57P JOBSITE ADDRESS 1.g5 ( 'Y Q ) E1 ) OWNER'S NAME',]J ) I'(fin M ` h tf 3h, POWNER ADDRESS m r TEL.7R_774 -IyO J IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL El RESIDENTIAL TV PRINT (� CLEARLY NEW:Li RENOVATION:® REPLACEMENT:` , PLANS SUBMITTED: YES 0 NOQ FIXTURES 1 FLOOR--, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1---- It I.� 11 IF I ._ �HE J-- J CROSS CONNECTION DEVICE L W ' i [ -1P [ i C. -.11 _I I _.. �- l_ DEDICATED SPECIAL WASTE SYSTEM f �I Jl - _^' �DEDICATED GAS/OIL/SAND SYSTEM �_ ![^ _ 1� l DEDICATED GREASE SYSTEM ;'_- ~.11 .. 1l - )'l DEDICATED GRAY WATER SYSTEM _ILi[ a_ ii- r _- DEDICATED WATER RECYCLE SYSTEM --1i --r------7 f--- - ,; .I1._. 1 -.dam. DISHWASHER [__ I DRINKING FOUNTAIN_ FOOD DISPOSER L t[ - 1__ if L FLOOR/AREA DRAIN ,_. INTERCEPTOR(INTERIOR) ir .1 r_ KITCHEN INK If LAVATORY I i I 1 I I-. L L..�_. ROOF DRAIN r ir.. — I ! SHOWER STALLS 1 __ I i SERVICE I MOP SINK I- 11 I [ �._ --..i TOILET lam I —t �...:a iL. _a� _ - URINAL l _ ,1; 1 ,L `[ .I _]- 1 WASHING MACHINE CONNECTION L. 'r 11 �.I 'r� I it WATER HEATER ALL TYPES II 11 it„, , I1[ WATER PIPING I yl F_L !L.r J�..,_ � OTHER it it , ii __�_r 1 I— 1 . i[ I� 1 -. _.7. _If _ T INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[21 NO Ll IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L'.i OTHER TYPE OF INDEMNITY 1:1 BOND Li 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 Li AGENT _..1 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 corn fiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOW 1 LICENSE# 12298 SIG R UJ MP[I JP CORPORATIONQ# 3281C PARTNERSHIPD# ILLCD# 1 COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 ' TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com 1 •(^"r \ A 1SC, IILIILVI{IYLbI{{I{ VJ l I1 Department of Industrial Accidents ►= t Office of Investigations =�� 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information , i Please Print Legibly Name (Business/Organization/Individual): t- W•c. lf\S Q,v CLLANIJkekci totl.,. Qt.,, 1tfl t Address: g' ar cvt C, P— City/State/Zip: Sos-cieN 'fcry ,c;., Mr- Phone #: 'US- `ck`l 1' '7 ? Are you an employer?Check the appropriate box: Type of project(required): i1 I am a employer with -7C 4. ❑ I am a general contractor and I 6. El 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 ❑ 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' comp. insurance required.] 13.❑ 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. tsurance Company Name: P j a" t�5Lvttr( ;- , r-k. ) colic)/#or Self-ins.Lic.#: $ a I f'c Expiration Date: lb Site Address:,;)3 i - .) p-e a-A 4"h .W 1 CGN~ 'r t City/State/Zip: O,)LI ( 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 dgainst the violator. Be advised that a copy of this statement may be forwarded to the Office of tvestigations if`the DIA for insurance overage verl lion. do herebycertify un e ains an, penalties o jury fy e pe that the information provided above is true and correct. gnattit : 4, A Date: i�_ 3 i aQ 16� hone#: SZ , y1 . 7 ?7 ' 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#: