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Home My WebLink AboutBLDP-19-001323 C MASSACHUSETTS UNIFORM APPLICATION FOR PE�TO PERFORM PLUMBING WORK .alw : CITYI A1114flll ' MA DATE 4,)2C6/ / PERMIT#/. l?/21?-00/3a5 JOBSITEADDRESS 5fr,v1Vk r&S IV1MI,t) IOWNER'S NAME MO bilhe1ah 1 P OWNS ADDRESS - 3(1 wrnrii Y'2 Rn YO/MOU M„TEL505f2`6 03l1 FAX TYPE OR OCCUPANCYTYPE COMMERCIAL 9 EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NOW FIXTURES 7 FLOOR-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ' ' CROSS CONNECTION DEVICE __ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOWSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED'GRAYWATER SYSTEM DEDICATED WATER RECYCLE SYSTEM __ -- DISHWASHER DRINKING FOUNTAIN _ FOOD DISPOSER FLOOR IAREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL I SERVICE I MOP SINK • TOILET _ _ URINAL WASHING MACHINE CONNECTION _ WATER HEATER ALL TYPES I WATER PIPING OTHER r - s • I r 1 r- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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 0 CI SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application ar true and accurate to the best of my knowledge .2--it- — and that all plumbing work and Installations performed under the permit issued for this application will be In mpllance with all Pertinent provision of the N Massachusetts State Plumbing Code and Chapter 142 of the General Laws. dte....- c7 v PLUMBER'S NAME STEPHEN A.WINSLOW 'LICENSE# 12298 # P.SIGATURE LIz' ICP MPD JP❑ CORPORATION El# 3281C PARTNERSHIP❑# LLC 0# r Cr COMPANY NAME EF WINSLOW PLUMBING&HEATING J ADDRESS 8 REARDON CIRCLE I -‘ 2'.. CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 2 FAX 508-394-8256 CELL N/A EMAIL (accountspayable@efwinslow.com I • 6.\ use s.vrrurwrs m usus vJ aratas.'I uswosw l*a t= Department of Industrial Accidents 2_ n� t Office of Investigations k. - y 600 Washington Street • `r.- Boston,MA 02111 ''`�' www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information c 1 Please Print Legibly Name(Business/Organization/Individual): E•c•Wtn51OW etUa..Oi.�et I �to, '.nq Cl) 1nC, Address: $' �eQcbn C dt. a OY City/State/Zip: Souk r•,c,,Ain Or Phone#: 1503-399-1177 XAre you an employer?Check the appropriate box: Type of project(required): am a employer with 70 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction :.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 1.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.9 Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.0 Other thy applicant that checks boz it must also fill out the section below showing their workers'compensation policy information. • Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. tsurance Company Name: A1''pps.,..f ("Auti/e-A (!1 suck t e yly )licy#or Self-ins.Lic.#: ($al Expiration Date: (—] — aOI9 )bSite Address:o23 COrIAPKVIvte0l-h t(,t-e/ Ct1e3 ,l4. [Vill City/State/Zip: Ca'I(t7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). inure 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 'up to$250.00 a da a ainst the violator. Be advised ti.t a copy of this statement may be forwarded to the Office of .vestigations the DIA or insura overage yeti a• on. do hereby certify un ains a penalties o p•jury that the information provided above is true and correct. Ill gnatuT • Dale: 101)3l 1 ao]7 (� lone#: cola:MI. 777g \ CIOfficial use only. Do not write in this area,to be completed by city or town official • City or Town: • Permit/Licehse# 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#: o.