HomeMy WebLinkAboutBLDP-18-005356 - n' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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s$ JOBSITE ADDRESS /=9�- u AO 1 OWNER'S NAME /U47,9 j
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OWNER ADDRESS �--- �/
TYPE OR OCCUPANCY TYPE COMMERCIAL 1
EDUCATIONAL L RESIDENTIAL ll
PRINT PLANS SUBMITTED: YES[ NOD
CLEARLY NEW:D RENOVATION:0 REPLACEMENT:
FIXTURES 7 FLOOR; M 2 3
-4 1_-®®�®9 10 11 12 13 14
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BATHTUB ®1---�-___':"®® L
CROSS CONNECTION DEVICE L. , _A-- ®®���NS ®®�
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DEDICATED SPECIAL WASTE SYSTEM ®I--_ ��C ® M_
' DEDICATED GASIOILISAND SYSTEM M�NNOW��MM ® �-�- -- `
DEDICATED GREASE SYSTEM 1- -_-r-- = -- - = _
DEDICATED GRAY WATER SYSTEM ] :1-- � (r _, i _7 i-- -.I_ , L- �_-_i 1 !
DEDICATED WATER RECYCLE SYSTEM [w 1__::__[TT 1_`-.E--='1 -y�-IL. JETT
DISHWASHER �1._: ®��®�®�®�®®®ial
DRINKING FOUNTAIN ®®®®®®®®- ®®®�® �� ®[ �
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FOOD DISPOSER
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FLOOR/AREA DRAIN M1- ®�®® �®®�®®®®
INTERCEPTOR(INTERIOR) ®L-=®® �®
LAVATORY ®®® ®®
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ROOF DRAIN ®®IIII®®®MIN®®M ®®® � 1
SHOWER STALL IM®®®L_.__:." ®® ®NINCIIWIL l ® I �U
SERVICE IMOP SINK ®�®®®® I _ . ---r®®_,___ ___ \ `
TOILET (N®�®I7-,®®®®NNNL: -_ii---_,�-- II111 -z
URINAL ®®®®®®®®�
WASHING MACHINE CONNECTION ®®�®n-®®®®� ®�,��_
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WATER HEATER ALL TYPES M®�®_-�==-''- (��,�,_..._11-_ . . i
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L �- "``�T i INSURANCE COVERAGE:
I have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 7- NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY
BOND El
does F
OWNER'S INSURANCE WAIVER:I am aware that the licensee
ot h waives this coverage by Chapter 142 of the
I Massachusetts General Laws,and that my signature on thispermitapplicationC")
CHECK ONE ONLY: OWNER ® AGENT
SIGNATURE OF OWNER OR AGENT e and accurate to the best of my
I hereby all u that all of the installations onsormation I performed have submitted or under the permit issued for regarding
s�applications application
will be in r p ance with all Pertinent provision of theedge
and that all plumbing work and t
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A.WINSLOW m _ _- . 1LICENSE#1.12298 _-
GNATURE
MP 0 JP® CORPORATION 0# 3281C =PARTNERSHIPLi#L-----� JLLCj# _ _?
COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE _LL —rs
I STATE MA I ZIP L02664 , _.1 TEL 508-394-7778 __ , p If
CITY SOUTH YARMOUTH l�C J
J—!EMAIL l accounts�ayable@efwinslow,com
FAX 508 394 - CELL NIA_--
A
The Commonwealth of Massachusetts \
°""e'er 1
— Department of Industrial Accidents
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:..f,[„� 1 Congress Street,Suite 100
Boston,Mel 02114--2017 I
im
0'.7 www.massgov/dia
Workers'
Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY A licant Information •
Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC Please Print I elbly
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH,MA 02664, phone#:508-394 7778
Are you an employer?Check the appropriate box: -
1.0I am a employer with 1( e Business Type(required):
or part-time).* -- mployeea(full and/ 5• ®Refail
2•El I am a sole proprietor or partnership and have no 6. DRestauranf/Bar/Eahng Establishment
7. El and/or Sales(incl,real estate,auto,etc.)
employees working for me in any capacity.
3.® [No workers'comp.insurance required] 8. 0 Non profit
We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c.152,§1(4),and we have
4.❑ no employees.[No workers'comp.insurance required]* 10.0 Manufacturing
We are a non-profit organization,staffed by volunteers, 11 Health Care
with no employees.[No workers'comp.insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#I.
I am an employer that is providing workers'compensation insurance for
lazy
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY employees. Below is the policy information.
Insurer's Address:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL, MA 02467
Policy#or Self-ins.Lie.#1821A
Attach a copy of the workers'compensation policy declaration page(showing the policyationDnu ber0and 1/2 expiration date).
Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
fine 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
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certli� �a ff11/
the albs and ena'ties o perjury that the information provided above is true and correct.
Si afire: --
rv` Date: i a)_ (//3 1i j
$. o39 ;78al use only. Do not write in this area,to be completed by city or town official •
City or Town:
Issuing Authority(circle one): Permit/License#
I.Board of Health 2.Building Department 3.City/Town CIerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person:
Phone#:
www.mass.gov/dia