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Home My WebLink AboutBLDP-19-002331 A \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK s-31' CITY I Y2rr'w44' I MA DATE I)O I Is I I B PERMIT#/ -1Ofl -C.0 " JOBSITE ADDRESS 9\ \o;kvsa15d'.`1gfrmnu1-kPo/k DINNER'S NAME InH'I 'Fund Antrim IVO!I?vel P 06,5 OWNER ADDRESS VII StrA'N1erS4'. Y�/moo+HP0lkMAf TEL 50cirl439$48 JFAXI 0?,6'15 , TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL ❑ RESIDENTIAL_ PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB - �I_ I —r EN--Ns Ns CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM �; DEDICATED GAS/OIIJSAND SYSTEM - ! -- DEDICATED GREASE SYSTEM INS -- — DEDICATED'GRAY WATER SYSTEM _ TIM-- ,- _ _ 7 - - DEDICATED WATER RECYCLE SYSTEM F� _ J DISHWASHER M' DRINKING FOUNTAIN _ lir— FOOD DISPOSER _ FLOORIAREA DRAIN . _ INTERCEPTOR INTERIOR --11—_ KITCHEN SINK M LAVATORY ROOF DRAIN - 1. SHOWER STALL SERVICE I MOP SINK ! TOILET MII URINAL Ali - - -WASHING MACHINE CONNECTION -lit WATER HEATER ALL TYPES MI WATER PIPING _ OTHER �i�Q1�.�. IS _, I a- - i I I 7 ___ _ ineSsill INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D 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❑ r�-� OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the V Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT c I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge v and that all plumbing work and Installations performed under the permit issued for this application will be in co liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. M s1-' VI qta PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE Q- M .0p:gb° MPD JP CORPORATION❑# 3281C PARTNERSHIP❑# LLC 0# ai 1 COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA ZIP 02664 TEL 508-394-7778 1 FAX 508-394-8256 CELL NIA EMAIL accountspayable@efwinslow.com I • • Saa 11.4 VVIILILWLLIY44Li1i.J IIINJJYL./LNJYLLJ === Department of Industrial Accidents liT_,' �= t Office of Investigations .600 Washington Street "i'` Boston, MA 02111 ' .‘t,---talk .. .www.mass.gov/dia • . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ' Applicant Information /� I 1 Please(lPrint Legibly Name(Business/Organization/Individual): E•C.Wt1�$I0W 0%10%00 a. Vitatil `e, )tn(. Address: $' (Zeorkvi CitiQ. Ol City/State/Zip: Sou kin 'fcro."0,1-1-1 NIc Phone#: 508-1394-117C) XAre you an employer?Check the appropriate box: Type of project(required): I am a employer with 20 4. 0 I am a general contractor and I 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions .❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' comp. insurance required.] 13.0 Other .ny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • Tmeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. um an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. //�� 1 surance Company Name: fkt m..s Kilnle-A i_nf e tt Cath vny tlicy#or Self-ins.Lic.#: I$a I A ,1` Expiration Date: (—I - D.0199 b Site Address:.�3 GVntvl�.freoi in Atf-e CFS }4. i U City/State/Zip: DaLl t07 1 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 \� ie 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 ts.t a copy of this statement may be forwarded to the Office of 1 ` vestigations the DIA for insura• - overage veri a,on. to hereby certify un • e ains a •penalties o truly that the information provided above is true and correct. gnatuT:• Date: la)31 l aovj 1 `\ tone#: co'L' 5`I' -7778 Official use only. Do not write In this area,to be completed by city,or town official �' • City or Town: • Permit/License# \ Q 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#: