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BLDP-18-002994 .� cb--0T-ifya_ - filer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT PERFORM PLUMBING WORK `� ' I =ni) CITYIMA DATEMtn�7 PERMIT#/. 40)•••-•,4%-00A7? JOBSITEADDRESS /L i t ♦ ,t _ _ OWNER'SNAMEI ' 0 a ti. Ai. r,. e_ sem. P OWNER ADDRESS • im . E. ..at•. .Ho )11 .Olt tall Tawftu-socrIFAxi j TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL-' PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES® NOD FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB V nyzam;st lNS- I IIIII_ I 10111 CROSS CONNECTION DEVICE lia. a — enS � e DEDICATED SPECIAL WASTE s __ � I��i ' DEDICATED GASIONSANDSYSTEM `—II ISWIN DEDICATED GREASE SYSTEM Sg a�1SSS S1SSS_� Q DEDICATED GRAY WATER SYSTEM Sant I_ lilt ian iSI Mini DEDICATED WATER RECYCLE SYSTEM srs [--• o SSaSS5 I fl DISHWASHER aS �a 'a— DRINKING FOUNTAIN ro__sso Man—am FOOD DISPOSERSIIIM5 S Il SS ■SAmi I� FLOOR I AREA DRAIN e ss Maets�aS1 1 — 1� O INTERCEPTOR INTERIOR S�I �fr-1aS�--1SanS KITCHEN SINK SIN 11 ��SSS1�SSSSSS .111 SHOWER STALL M' LAVATORY �MI'�� IM S ROOF DRAIN SINSMIS � 1�MI�SS��SS�1a ailinlaiWINIInallta SERVICE/MOP SINK � � �I 1 anallglTOILET a r��rr�I URINAL i_4 SIS SSSA'i�'�SSSSSI_ WATER HEATER ALL TYPES I®*SSSSSSIMSSSSL S_ WASHING MACHINE CONNECTION INIESSMI�r— lit1, aniglorneall OTHER �.- i�!r �l iligaSlismillliklitSSSlilliS SSISIMSS INSURANCE COVERAGE: I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E+ NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW i LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY D 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 'p 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 co fiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. . / ...24,Z.— PLUMBER'S NAME STEPHEN A.WINSLOW ILICENSE# 12298 SIGNATURE MPO JPD CORPORATIOND# 3281C PARTNERSHIP®#Ma LLC®#111111.11111 COMPANY NAME EF WINSLOW PLUMBING&HEATING i ADDRESS B REARDON CIRCLE CITY I SOUTH YARMOUTH 'STATE MA ZIP 102664 1 TEL 1508-394-7778 1 • FAX 1508.394-8256 1 CELL NIA EMAIL I accountspayable a(�,efwinslow.com 1 - g 4b • ,i1 � 3 . • The Commonwealth of Massachusetts I ='-=t= t ES% ' pepartment of Industrial Accidents re mnig 1 Congress Street,Suite 100 I_E Boston,MA 02114-2017 • e cad,ay www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664, Phone#:508-394-7778 Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with 10 employees(full and/ 5• 0 Retail 2,0 or part-time).* 6. Restaurant/Bar/Eating Establishment I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees.[No workers'comp.insurance required]** 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 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#1. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address:23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL, MA 02467 Policy#or Self-ins.Lic.#1821A Expiration Date:01/01/201R Attach a copy of the workers'compensation policy declaration page(showing the policy number and 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 pp��--‘b...:". Investigations of the DIA for insurance coverage verification. \ \ / t do hereby certi the alias and enalties o perjury that the information provided above Is true and correct v Signature: Ira"-, ,,,,,a a.... Date: /a. (31 /143 ti----\1 phone#:508-394-7778 Official use only. Do not write in this area,to be completed by city or town official ..\ City or Town: Permit/License# V Issuing Authority(circle one): I • mo. 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office � ' 6.Other 54 Contact Person: Phone#: www.mess gov/dia • ; s