HomeMy WebLinkAboutBLDP-17-003725 MArSAOI 7.SSE�T TS I t AFO1 RJI SAC PII.ZA a R.Od 1 FOR A PERafire TO FER;=CR1G9 FLt I:VI lM WORK
CITY -� G7'�L\- -,. .,.._,� MA DATE ; ; PERMIT# P✓l,/I/2/7—CO 7z‘
JOBSI T E ADDRESS ! OWNER'S NAME Ct2
f t
P OWNER ADDRESS( �. �-� ti::�. ���� ..._,r �} TEL 7J�7/q AXI. .. , l
TYPE OR OCCUPANCY TYPE COMMERCIAL r.I1, EDUCATIONAL Li RESIDENTIAL
PRINT
CLEARLY NEW:U RENOVATION:L REPLACEMENTA 4 PLANS SUBMITTED: YES ,j NOL1
FIXTURES 1 FLOOR-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1-.: _ ' 1 I I I I 1 '( l I I ( r [ ,.
CROSS CONNECTION DEVIC I ( rE a _ .. { I
_7 . ... . ( I 11. Ir
_ _ _
DEDICATED SPECIAL WASTE SYSTEM r:_. f— r ( I ( ^r— 'r r ii _•_ '{ I _). I. :_
DEDICATED GAS/OILSANDSYSTEM r. I _, _ :i .1 {— i. , I ..: 1i ,1- { _z 1 !E.._.::L__ i.=
DEDICATED GREASE SYSTEM t _ � _ 1 _ --7 1
DEDICATED GRAY WATER SYSTEM I... :._ •I I r I r .. 1 - I r.. '� ..'L r I
DEDICATED WATER RECYCLE SYSTEM 1( ..i _. F,--7-7;I,. . 7,-7.1.,... 1-7' ., r. . I I -7r f. .. -_,I_.
DISHWASHER I �' I r- ( rr 1 I I r-_i r_ I Nr.
DRINKING FOUNTAIN _ { 1—�-'{ I r. ( Il r r I --
�r_ I I .. I 1I 1. 'I ! :(^'1..
FOOD DISPOSER {.,. I , _
L FLOOR 1 AREA DRAIN 7.77 I -I I r---i— I I 1-7 i 17 . I i
pAz
INTERCEPTOR(INTERIOR) 1 { r g[ (--r il r- ;i r _. 1 iF r --
M KITCHEN SINK I {• 1 ( r' i .... I • r i I, I r 1Ti
'' J LAVATORY I E-- rt(—_f_-I 1 r -i r j- r- -.11---- I 1.��
a� ROOF DRAIN I ;1 I r7 r 1-------:[-,-.----I I . I I :I 1 -
SHOWER STALL 1 __ f` I I r� I , L i I I� r 1
SERVICE/MOP SINK 1.,_ ..,1 _ . r—i f--t.. .. ( .: . r 1r I,._ ,s ',ETA,- -_:1 1,.
TOILET r 7-7I I_ I 1. I
URINAL I. I ,I l rr_
-A — r —ir r— 11 -'1 f- II 1--�r-
WASHING MACHINE CONNECTION I 1 1 —[ I—, a -- 'r L ;1.....__,:
WATER HEATER ALL TYPES I_%Vj u w�1 I r. 1 I I I _ I I 1 1
WATER PIPING r y I 1------F----j - r r 1 1 11 °I —7 1 i _
1 1 f _. ,r 'i 1 I r
OTHER .• � � �� r � _. 1 � -•-- I _ -.1 :.r _._., � Tf _. !1
-- I
I-
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY El 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 0 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 corn nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A WINSLOW , LICENSE# 12298 SIGN TURE
MPO JPU CORPORATION 0#J3281C_ �JPARTNERSHIPC#I , r...,....1LLC[_ #L R
COMPANY NAME E F WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE 1
CITY SOUTH YARMOUTH STATE MA I ZIP 1 02664 I TEL 508 394 7778
FAX[508 394 8256 CELL N/A I EMAIL acc ountspa ably+ e22 nslow.com 1
9),
1)) }, ' "t i `
tii l � ,l
1.��411.VRJ
91.9
ria ,: ! msEotn�,l;mil 0LL7L •
a5' �'�. www Giidvadogovige
Joiskeres' (Cotnpcensatsora II120. re 1EaCa AiildSIVY1 i lallderes/Contreacton/11,T Mlle cn aslanu e en
'leantI(vrv.®li°l�rnatuomt 1 py�� L y�
G.
t0(Business/Organization/Individual): i. w S• ` J
tress: ,fa lP.,
;T/State/Zip: Soo 41/‘
c,,. CAA- Phone#: 'it) -an`i-'. 1
Type of project(required):
you an employer?Check the appropriate box: g• ❑New construction
I am a employer with -70 4. 0 I am a general contractor and I
have hired the sub-contractors 7 El Remodeling
I amoyees(fool and/orrpart-hme) listed on the attached sheet.
] Iship a sole proprietor employees pestner- These sub-contractors have 8. ❑Demolition
ing hove eo nnyp workers' comp.insurance. 9. 0 Building addition
working for me in any capacity.
[No workers'comp.insurance 5• 0 We are a corporation and its 10.0Electrical repairs or additions
officers have exercised their 11.0 Plumbing repairs or additions
require .] right of exemption per MGL
lf.
I mitt homeowner doing all work and we have no 12.0Roof repairs
mysrnce required.moored comp. c.152,§1(4),employees.[No workers' 13.0 Other
insurance ]t] comp.insurance required.]
ion.
applicant thato submit
box#1 mustv alsoindicating
n cal out tthe
e section
doingbelow
all work and then hire outside contract compensation
rs must submit new affidavit indicating such.
omeowners who submit this affidavit shed ag y
policy information.
ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'come.P
insurance for my employees. Below is the policy and job site
➢�e an employer that is p rovidin g workers'compensation
orrnation.
Name: e ��' (`Uril e_ t n s 'n T j
;uranceCompany �—1 r ��1�
`$,�` Expiration Date
licy#or Self-ins.Lic.#. �n —
�.�itEN A-e e 3\,t,>' I�t1 City/State/Zip: 14_�—
b Site Address:�.� �^^r```a���
Mach a copy of the workers' compensationpolicy declaration page(showing the policy number and expiration date).
secure
coverage as required under Section 25A of MGL c.152 canlead e form of a STOP WORK ORDER and a fine
imposition of criminal penalties of a
i dime to one-year imprisonment,as well as civil penalties ze up to$1,500.00 and/or be forwarded to the Office of
'up to$250.00 a da against the violator. Be advised t 1 at a copy of this statement may '
vestigations• the DIA for insurape- overage verir a on.
o':� jury that the information provided above us true and correct.
da hereby cerifyun,e`,ik,._ penaltiesainsan. V.
�
(( Date: Q' - i aolf,
is atu3- r� �-
hone#: • •`t- '7 77X
Official use only. Bo not write in this area,to be completed by city or town official.
•
Permit/License#
City or Town;
Issuing Authority(circle one):
card of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
1.B .
6.Other
Phone#:
Contact Person:_______--------