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Home My WebLink AboutP-19-851 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,r=I6 tY ,,p�� n r1== CITY YaIMd W'h ] MA DATE ,. RM= PERMIT# /�1"'/!" gVl JOBSITE ADDRESS C(4 Wt..e OWNER'S NAME R, Rn he44 5 ,/an I P OWNER,ADDRESS IOSI R+. a% S. YwnouJh MA TELISOQ394o(7riFAx oaGCY TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL„ PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:E / PLANS SUBMITTED: YES 0 NOO FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB Ma— CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM 0111111111.6MOSSIMMII i111E MIN M DEDICATED GASIOIVSAND SYSTEM DEDICATED GREASE SYSTEM _ _ DEDICATED GRAY WATER SYSTEM ... DEDICATED WATER RECYCLE SYSTEM DISHWASHER t I DRINKING FOUNTAIN _ M_ , i FOOD DISPOSER _ FLOOR I AREA DRAIN _ INTERCEPTOR(INTERIOR) .. _ _ KITCHEN SINK r 1111 LAVATORY ROOF DRAIN S _ - SHOWER STALL SERVICE I MOP SINK TOILET - i URINAL -riWASHING MACHINE CONNECTION fJ WATER HEATER ALL TYPES V WATER PIPING OTHER?01it N1.P1f^0 , r--- Un f/- 11 J - - - l INSURANCE COVERAGE: (.-, I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑ CP IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 BOND 0 -c— 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. Cr CHECK ONE ONLY: OWNER ❑ 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 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 romance with all Pertinent provision of the QMassachusetts State Plumbing Code and Chapter 142 of the General Laws. ....d..: ' / PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIG ATURE I MPO JP CORPORATION❑+ # 3281C PARTNERSHIP0# LLC 0# COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 18 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA ZIP 02664 TEL 1508-394-7778 I in_ FAX 5083941256 CELL N/A EMAIL accountspayable@efwinslow.com 1 • Sa l In. , WIII1,4M44II J IIIMUJIf4I. 1J4440 _w=,= Department of Industrial Accidents t• _ Office of Investigations , t it l_a ; 600 Washington Street Boston,MA 02111 • 41=t www.mass.gov/dia • • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C Please Print Legibly Name(Business/Or/ganization/Individual): Ef .W1 SI OW YIU�6.✓� et �CO-1" , Ce, IelC• Address: g &eodnn Cid a d City/State/Zip: Sou kin ' rt-' ,,kn tN,ar Phone#: 'SUb- 399-117S1 Are you an employer?Check the appropriate box: Type of project(required): Xam a employer with 70 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors :.0 I am a sole proprietor or partner- listed on the attached sheet._ 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions i.0 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 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] my 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. /� � isurance Company Name: flrtm,.r r%.t-ua l �1ruck nC..e_ Cel: 1� i olicy#or Self-ins.Lic.#: 13 a 1 tExpiration Date: (—[ — ail 9 r �p )b SiteAddress:� Cr 3 ncnw-eo.IT,h AHU ; CFe3� PA City/State/Zip: Cly-1to7 `1\I 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$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 da a•ainst the violator. Be advised t I:t a copy of this statement may be forwarded to the Office of tvestigations . the DIA for insura• - overage verif a,on. do hereby certify un • .e ains a penalties o p•jury that the information provided above is true and correct �^ ignatu =• Date: (al 31 1 ao(7I �Y hone#: cut 311`1. 777x Official use only. Do not write in this area,to be completed by city or town official " �l • 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 I 6.Other Contact Person: • Phone#: