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HomeMy WebLinkAboutBLDP-19-001481 Sart 97,-4-1 e MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK 4 E _ f CITY��.L_ /.r -a� an '1 MA DATE[I�IIIC PERMIT#�) n • JOBSITE ADDRESS* ri eaI OWNERS NAME X,1 s , OWNER ADDRESS p OCCUPANCY TYPE COMMERCIAL® EDUCATIO ® TEL - yi. lislis FAX J!. RESIDENTIAI.I�/ TYPE OR PLANS SUBMITTED:YES® NO +� PRINT CLEARLY NEW:® RENOVATION REPLACEMENT: FIXTURES i. FLOOR St0©©QOStaTaitiontstiamIts —s — ' CROSS CONNECTION DEVICE 1��I�� ������ I � el •-.....‘_ DEDICATED SPECIAL WASTE SYSTEM i MI _ ! '1 , j I1 19� a - ES 1 DEDICATED GREASISANDSYSTEM �- I ' 4 .. IK IPIS DEDICATED GREASESYSTEM -Kt DEDICATED GM?WATER SYSTEM IaiI_� ` sssINITIOnainlittliallaISIMIllrr- itSSISSIKSIS alV DEDICATEDWATERRECYCLESYSTEMn I DISHWASHERRKINGFO a. DRINKING FOUNTAINSI1. FOOD DISPOSER FLOORIAREADRAIN _ I — INTERCEPTOR INTERIOR Mini ' VV LAVATORY Sr MWIS [ISCJSIPIWISil ROOF DRAIN EJIEJ$EJIII$5!a5 all OISSSMINSIISIOSISSIfi WASHING MACHINE CONNECTION ssmast OTHERreassila � �r ! alts o _ `F a ( ds . INSURANCE COVERAGE ' ^ , I have a current iabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[ NO 0 0--J IF YOU CHECKED YES,PLEASE INDICATEThETYPE OF COVERAGE BY CHECKINOThE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHERTYPE OF INDEMNITY® BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the t,0 Massachusetts General Laws,and that my signature on this permit application wai_ vesthisregHEment. ONLY: OWNER® AGENT CK El SIGNATURE OF OWNER OR AGENT pp knowledge I hereby certify that all of the details end Information I have submitted or entered regarding this application are t and accurate to the best of my and that ell plumbing work end InstallaUpns performed under the penult Issued for this application will be in jr.ncewith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. IG�'TURE PLUMBER'S NAME STEPHENA,WINSLOW LICENSE# 12298 LLC®# MPa+ JP® CORPORATION[+ # �_ PARTNERSHIP®# CITY SOUTH YARMOUTH HEATING ADDRESS B REARDON CIRCLE COMPANY NAME EFWINSLOWPLUMBING STATE MA ZIP 02664 _- TEL 5083947178FAX 5083943258 CELL EMAIL accouMs,a able aefwlnslow.com in414 to s, 1 , , t =! / The Commonwealth o Department yMt4cc dents. of efr0 Z CongressSYreef,Suite 100 Boston,MA 021142017 • Workers' • www.masagov/die 20 BE°BILPEDaflon Insuranca.4ffidavft:General$asinesses. A.,IicantInformation • WPPHTHEPERMITfINGADT$ORITY. Business/Organization PIease print Be•ibl • Name:E.R WINSLOW PLUMBING&HEATING CO„INC • Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH Are on a ,MA-02664, phone#:808394.7778 Y n employer?CheeICthe appropriate box: 1'Cl✓ I am a employer with �� Bustne e or part-time).* empIoyees(full and/ S. ORetad a(reuired); blishment • 2,® Iamasole proprietor orpartnership and haveno 6. QRestauan/I3ar/Eatn • [No employeesworkingcamp,insurance capacity, 7. 0 Office and/or Sales(incl.neal estate,auto,eta.) 3 0 [Nowe workers' a mp.insurancerequire orporatlon and its officers have e 8. 0 Nan-profit their rigbto£exemption per o.152 ° exeresed noemployees.righto ,§l(4),andwehave 9. DEan�mmeng 4❑ no ye [No workers comp.insurance required)* 10'�]Manufachn ng with re anon-prof[No workers'staffed by volunteers, 11.E]Health Cara +Myeppu ithntc5eploye comp.Insurance req.] 12.0 Other corpora, ch PtWiout the section below showing thekworkers'ca 1"p • Anyapo emhave exmn **lithe corpora,officer's haveex themselves,butthecorpompan has other prkelyn nsagonn o Iamanem emp]oyees,axrorken'co a ployerthattrproYldfn dense°onpolicyia equuedendsuchen Insurance Com workers compensation Insurance for Company Name: INSURANCE CO f my employees. Belowfsthe policy Inavrer'sAddress:23 COMMONWEALTH AVE COMPANY P cylnformatlon City/State/Zip: CHESTNUT HILL,MA 02467 Polley#or Self-ins,LIo.#1821A Attach a copy ofthe workers'co Failure to secure coverage as re mpensat on polic de Exphntion Date:01/01/201 P $ecure.coerage required yAofMGLoa52(ca lea othepiponumbefaiminalpenaond- e to erSection25 finof to one-year Imprisonment naJ esinthefc theimpositione P $250.00 a day against the violator. s well as civil penalties in form ofea STOP ed to ORD . ! ....kt)r\y‘ Investigations of the DIA for insuranceBe�e advised penalties es of a cover that a copy of this statementma 13R and afiue Iola hereby c a6averrfjca5on, Ybeforwerdedtotha0fficeo£ Y erfl . :.. , n,E0,. perlarythatthe Information provldedabove lrtrueandcorrect \ Si_ afore: ‘. IL hone 508394-7778 • �� Date: 0 011claruseonly, DonotwriteInthiisarea,tobecompletedbyetf,ortownofffclaZ • t p City er Town; , IssuingAutfority(circle ne): Perm/if/Accuse# 1.Baardof$ealth2.$uldingbe a h/To 6.Other P rlment 3.Ci waCterk 4.Idcenstngl3oard S,SeIe ContactPersont cinrett a Office Phone#: wenmeassgov/dla ,