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HomeMy WebLinkAboutBLDP-17-003533 ti rSA::,.-vrSE7YE11(VErDR[11lAFPLuCAuiOi'l ;:0RA RW71a 70 ER;=C Rail EI'pl r.lh'ZIMSIBCr:V,t fir; CITY 1 _ � , „.. MA DATE I, - P RMIT# JOBSITE ADDRESS 7 —- : * OWNER'S NAME „_ „ ,. ......�-.. -.-�1 OWNER ADDRESS / _ TELlq/7-,5 9d7. :FAX __ TYPE OR OCCUPANCY TYPE COMMERCIAL L-.1 EDUCATIONAL 0 RESIDENTIAL PRINT PLANS SUBMITTED: YES Q N0 CLEARLY NEW:LI RENOVATION:I� REPLACEMENT:gje FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB r 1 it I - I- 1 4I ,I I: r r r NNW CROSS CONNECTION DEVICE I r.- I :-. L - I 1_ 1--�1 I i DEDICATED SPECIAL WASTE SYSTEM r_< -_- . - :(_ - . 1 ., r-.. _ '1. r _ •_I :. I r ,I _y_ DEDICATED GAS/OWSAND SYSTEM ;:i •I- .. 1 J ! I DEDICATED GREASE SYSTEM 1:.. . ,_ill ._ i:I 1.,.. i, I z..,..,_: .,:: _.r '(, , r I IL....._ t : .._... DEDICATED GRAY WATER SYSTEM I 1 "I 1 I j _� ' - DEDICATED WATER RECYCLE SYSTEM I {.__,. I, . I,- : .. I,. . L [ . - :r. 1.Y I :: r r ( ,. .._ DISHWASHER • ,_- DRINKING FOUNTAIN ��__ --'1 . :. L. .. I �, 11 r _ 1 FOOD DISPOSER .....;. 'I--, I ,. 1 -:I: ,: I.,,,.. I,, .... I '1 1, - 11- . I __'r I1� : FLOOR/AREADRAIN %I L. I,: r - INTERCEPTOR(INTERIOR) i,._. r r r 1 .'I f. 1 -- 1---1 � KITCHEN SINK i _ 1 1 . I:. I I r L Imo- I _ iEll LAVATORY I:.,,,, f:- 1 . .;'C-` I I_^ 1 1 17 +r!_r- r '{� ROOF DRAIN I,.,. 1 SHOWER STALL r.^-7I I 'I .17 . i.....,.'1 i r- r- 1 N.r --I----: I SERVICE/MOP SINK :r r I `r`I�-_-17, r _II ;I:- _'i - ^i MIIO_- -� TOILET - ...._ I 1 1. . I...�•r--� iiiiiiiiiii WASHING MACHINE CONNECTION TIT [ 1 r �..p .I:_.. I :..1 .. ... 'r _.._:.�iE --,p----il. ,r -; MiN L 1. .:. _1 ..___ , WATER HEATER ALL TYPES i I I . i _. 1 _ -` WATER PIPING 1 ,7 I ^1_ '1 r --r._:._.:L .-._-!1 7. 'I iI - _ I I f__- OTHER L :, 1 I r - f I. 'I I ..i a . 1 r !i I -_. I 1 -1 7:- r 1. I r. l I 1 - c.. I, .. r.- : 11E _. L .._. 1, .1., -- r,-: -r ll.,_ . ..I . ,. .: .I:,. . s_._.,W_..., : . ,. . ... _..,, �.� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 3 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 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 ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _(/LL-t Lr.. :"3LL., PLUMBER'S NAME!STEPHEN A WINSLOW _ __,..,...._.__.P.. LICENSE#�,12298 • „I - SIGNATURE MP JP CORPORATION El#J 3281C ,,, PARTNERSHIP1J#L. . ... ..........i LLCLJ# ___a, COMPANY NAME E F WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE . _ 1 CITY SOUTH YARMOUTH 1 STATE MA ZIP 102664 TEL 5088394 7778 1 FAX 1508,394 8256 i CELL NIA EMAIL 12299untspayablegefwinslow.com ..._._ ),?., d a 7 v ° r.i ni ' I th - alp 5� �� i�TP3/�Il6Ctli a�a���• I IlI�US�A��li rorePores' cColnpeLr'iullom I�ci> ran A 3isivii:Bona detcs/cC®m ragto Ile �e r t�ebne • noa�nt O Iat tOM 9 y e(Business/Organization/Individual): E^1.\.,v i \5 t®v l " [V�.�O iv�tcci L It,e•o�'vr Qt.1 l ett ress: (i. ®'c c rek.� . Q /State/Zip: "Soo kit,k '-i" k`-kP Phone#: 5DS-�'aT1-11'icl • you:n employer?Check the appropriate box: Type of project(required): 4. 0 I am a general contractor and I 6. ®New construction I am a employer with �0 — d the sub-contractors hir ed re employees(full and/or part-time).* 7. ❑Remodeling listed on the attached sheet.1 8. ❑Demolition I am a sole proprietor noie emr ployees These sub-contractors have ship and have meo inany workers' comp.insurance. 9. 0 Building addition working for any capacity. [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11 ❑plumbing repairs or additions required.] right of exemption per MGL I am a homeowner doing all work c.152,§1(4),and we have no 12.0 Roof repairs myself.[Norequired.]workers'comp. employees. o workers' . insurance t � 13.0Other comp.insurance required.] n policy y applicant wthat o submit box#I must also indicating theyll out the section a a doinglow showing their workers'all work and then hire outside contractors must submit information. new affidavito indicating such. �meowners who submit this affidavit a n. ntractors that check this box must attached an additional sheet showing the name of the sub contractors eAd their workers'comp.policy rovidin workers'compensation insurance for my employees. Below is the policy and job site rn an employer that is p g ormdiion. el �,✓1�i ;urance Company Name: � '��,as C-V-O't1 t-)i s 1SAIA" Expiration Date: 3-1 r a�l/ licy#or Self-ins.Lie.#: olioe b Site Address: .� Lonnrke✓1 v al A , One3 -'---City/State/Zip: ttach a copy of the workers' compensation policy declaration page(shouting th p Y number and expiration date). dlure to secure coverage as required under Section 25A of MGL c.15 canleead f the imposition a STOn WORK ORDER and a fine ie up to$1,500.00 and/or one-year imprisonment,as well as civil penaltiesbe forwarded to the Office of 'up to$250.00 a day against the violator. Be advised t;tat a copyof this statement may / vestigations heDIAfor insuranc' overage veri..,a+on. hereby certify un'e- e pains an%penalties o`r jury that the information provided above is true andn correct. doh y (( Date: � - i a©kg' is atu3:• '• r hone#: 'l- 7 77 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 Phone#: Contact Person: