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Home My WebLink AboutBLDP-16-0042585 � P16- 089 1W MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT # - JOBSI EADDRESS n OWNER'SNAMEJ1'kp. hIPQ - POWNER ADDRESS I 3MME TEL - FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL D PRINT CLEARLY I NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NOD FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB IF - CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN 10 FOOD DISPOSER I FLOOR /AREA DRAIN I INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY D OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 ❑ 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 complia ca with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /' J PLUMBER'S NAME I STEPHEN A. WINSLOW LICENSE # 12298 z SIGNATURE MPD JP❑ CORPORATIOND# 3281C PARTNERSHIP ❑#LLC ❑#0 COMPANY NAME I EF WINSLOW PLUMBING & HEATING ADDRESS FREARDON CIRCLE CITY I SOUTH YARMOUTH ISTATE MA ZIP 02664 TEL 508-394-7778 FAX 508.994-8256 CELL NIA EMAIL [;T*u;;payable@etMnslow.com 5 � P16- 089 1W 02� Department of Industrial Accidents Office of Investigations 600 Mashington Street Boston, MA 02111 tvivtt.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): E'F• W tr\,51 oV-J oti,-Ato� Address: TL 4ntlun C_Irr p, City/State/Zip: Soo �h Ycry- ,,Jtn NA Phone #: `SUS- 39i-11?� Are you an employer? Check the appropriate box: Type of project (required): XI am a employer with 70 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).' '. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working lfor me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] i. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ 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' 13.0 Other comp. insurance required.] _ —kny applicant that checks box #I 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. /n� � n tsurance Company Name: P"fY�i N -J HJU" t nJ (yck A CIL olicy # or Self -ins. Lic. #: I ea a I A Expiration Date: 1b SiteAddress:D3 Atte, CI^e3W' 14 City/State/Zip: O,)r-Ilo7 ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure 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 S1,500.00 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 day against the violator. Be advised that a copy of this statement may be forwarded to the Office of do hereby certify und?rt(e pains and penalties q/(pe%jury that the information provided above Is true and correct. hone#: Si)9-354, 7?79 Official use only. Do not write In this area, to be completed by city or town officlal. 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 th 1 r. -. -s.._--- __ e 2/11/2016 SlipGen- Portal Hone PW Town of Yarmouth Template [Building Dept] i2m Slipsheet Identifier [sg39808] Document Category Building Permits Map -Block Number 014.2 Street Number 0361 Street Name GREAT ISLAND RD Department Building Parcel ID 93 Backfile Batch Scan No Document? Additional Naming Info Index Operator Operator, Yarmscan Date - Time 2016-02-11 - 09:49 httpJAaserfiche12/Sl1pGerW 1/1