The URL can be used to link to this page

Home My WebLink AboutBLDP-19-000830 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .-, W CITY Y/.1r11fl (� J MA DATE IccI62f/q PERMIT#I�I✓JJ�R'D0T0R NL---' JOBSITEADDRESS cant.{ &s kp low 'I/ OWNER'S NAME (Mc c evil i+1 P WNEADDRE RSSI ,ktP I)t Snt/ b Y/ofAtUl��y1 11 TEL 504 Ott-137,5 FAX TYPE OR OCCnUPANNCYYTY E COMMERCIAL EDUCATIONAL 0 RESIDENTIAL Er PRINT CLEARLY NEW;❑ RENOVATION:❑ REPLACEMENT:Ir PLANS SUBMITTED; YES❑ NO0 FIXTURES 7 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB se : im_ , , __ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM iIUIPhi DEDICATED GREASE SYSTEMDEDICATED GRAY WATER SYSTEMDEDICATED WATER RECYCLE SYSTEMDISHWASHER DRINKING FOUNTAIN �t k FOOD DISPOSER ma FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 11111101111.1111 LAVATORY ROOF DRAIN ' SHOWER STALLI SERVICE I MOP SINK TOILET , URINAL L WASHING MACHINE CONNECTION if r l r WATER HEATER ALL TYPES I WATER PIPING OTHER r ,I 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ej NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY 9 OTHER TYPE OF INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 0 Massachusetts General Laws,and that my signature on this permit application waives this requirement. tf' CHECK ONE ONLY: OWNER D AGENT ❑ .4;. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true 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 compli with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. fr., gl PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGN TURE MPD JP❑ CORPORATION❑# 3281C PARTNERSHIP0# LLC❑# " r- .=- COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE _.t CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL NIA EMAIL accountspayablenc,efwinslow.com I CP if 5° Gt • Sga a M. a.vusswn rr..wsan J s.awuuw..usw..s ' _iiihriDepartment of Industrial Accidents 'i"' Office of Investigations t =.I_= 600 Washington Street , , ` Boston,MA 02111 — r f. r . ' : www.mass.gov/dia , •, , , . . .. •' r Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name(Business/Organization/Individual): E.c.w1.,51Ow CiU✓M6i✓tcd A. t4{czt+.nq Ce, I.i(. Address: B' �eo itvi C*de.- City/State/Zip: i _ U 11X City/State/Zip: Sou sfl ' r c.,.rF1n Nftr Phone#: '508. 399-1'1?CI —Are you an employer?Check the-appropriate box: Type of project(required): `X;am a employer with "70 4. ❑ I am a general contractor and I 6. ❑New construction • employees(full and/or part-time)." have hired the sub-contractors :.0 1 am a sole proprietor or partner- listed on the attached sheet.t 7. 0 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. 0 We are a corporation and its required.] officers have exercised their 10.9 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 12.9 Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp.insurance required.] thy 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. /� tsurance Company Name: f7Yyp,.,J t"1J t-i (_Etf etCP_ CM Z.4y olicy#or Self-ins.Lic. • - A Expiration Date: (—[ — aol9 )b SiteAddress:a3 4-.—.N1/4; ih )&Q/ Ctregj Wit City/State/Zip: Oa4to? ttach a copy of the •or • . .-- •atio olicydeclaration page(Showing the policynumber and expiration date). P g ( g P ) ailure to secure cove age . -.. . r . ction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to$1,500.00 a d/or o . . ..:'isonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine J I up to$250.00 a da :;ainst the violator. Be advised t..t a copy of this statement may be forwarded to the Office of J tvestigations . the DIA • insure. - overage verif a on. do hereby certify un - e ains a penalties o p•jury that the information provided above is true and correct i_ atilt: / Date: 1a /11 aol7" hone#: ctd:3114. 777x \ Official use only. Do not write in this area,to be completed by city,or town official \ {' • 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 InspectorcS1 O 6.Other -. Contact Person: Phone#: