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Home My WebLink AboutBLDP-19-001106 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK %=`W/ CITY! Id(10Q+% I MA DATE I qb ix() /I7{7 PERMIT#fl6PW 0' /166 JOBSITEADDRESS $all! CA ) hpIffriM IOWNER'S NAME Maflthro J-1)15Zaf P r ,� 4,D4Ei HS Eldfic5-e Rrr. SaJI-In YafgOJ4t I TEL!cO%3gU 1654 FAX TYPE OR OCC P NC TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: �.�� PLANS SUBMITTED: YES 0 NO0 lad 1 AO FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB __ DEDICATED SPECIAL WASTE SYSTEM �_ � e� llat _ CROSS CONNECTION DEVICE DEDICATED GAS/OIL/SAND SYSTEM `�� - DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM � DEDICATED WATER RECYCLE SYSTEM _ �_ DISHWASHER DRINKING FOUNTAINf fi k _ __ _ • FOOD DISPOSER . _ - FLOOR/AREA DRAIN - _ _ INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY - _ ROOF DRAIN M SHOWER STALL SERVICEIMOPSINK - TOILET URINAL _ _ _ WASHING MACHINE CONNECTION _ _ - - WATER HEATER ALL TYPES ' WATER PIPING OTHER 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 WI�L7C.R'.Pam aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Genera aws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT 0 sO SI 4ATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are t and accurate to the best of my knowledge and that all plum Ing work and Installations performed under the permit issued for this application will be in co iance with all Pertinent provision of the Massachusett tate Plumbing Code and Chapter 142 of the General Laws. /Z tie O PLUMBE NAME I STEPHEN A.WINSLOW !LICENSE# 12298 SIGNATURE V --r MPO JP CORPORATION # 3281C PARTNERSHIP❑# LLC DI C_,.., COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE I cp ? CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 CI- FAX 508-394-8256 CELL NIA - EMAIL accountspayable@efwinslow.com I M* so 1I • Sga a I114 V WIIIY4µµ.i V JILIWJ0i4IifJ4i&J I Department of Industrial Accidents _;z4il1 �t Office of Investigations k _ I l_ ii 600 Washington Street Boston,MA 02111 art www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information c MPlease Print Legibly Name(Business/Organization/Individual): E,c-WirkSIOw ChU. lir,3 L tt0.�✓�, ea) Int• Address: B' keoatin Catf t2.. 0 I City/State/Zip: So1/415M Yon-sty-Ain t4Pc Phone#: 'DE-399-117c1 Are you an employer?Check the appropriate box: --Type of project(required ): Xam a employer with-70 4. 9 I am a general contractor and I 6. 9 New construction employees(full and/or part-time).* have hired the sub-contractors :.9 I am a sole proprietor or partner- listed on the attached sheet._ 7. 9 Remodeling ship and have no employees These sub-contractors have 8. 9 Demolition working for me in any capacity. workers'comp.insurance. 9• 9 Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required] officers have exercised their 10.9 Electrical repairs or additions t.❑ I am a homeowner doing all work right of exemption per MOL 11.9 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, kny applicant that checks bo'x#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. /� tsurance Company Name: /IYpph,-7 tL e-A i_ fuktr.4 el etthyly alley#or Self-ins.Lic.#: I3 a I A • Expiration Date: (—I - ao19 An Site Address:a3 n.fleJ}h Md-ei Ct e.4(14. IAA City/State/Zip: 00 4 67 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). adore 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 ante fine up to$250.00 a da a ainst the violator. Be advised t t a copy of this statement may be forwarded to the Office of ] \ vestigations the DIA or insure overage yeti a on. —� Ip� do hereby certify um s a penalties o p jury that the information provided above is true and correct. gnatu • A Date• (a)31 ) a017 lone#: 5j)VVH. 777 - ` l\ Official use only. Do not write in this area,to be completed by city,or town official _ • \(\�a • 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#: ,