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Home My WebLink AboutBLDP-19-002565 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK c='d_ aI CITY I Yarn-IA/4k I MA DATE' I(1 / i 9 /!Qi I PERMIT#, D P-/9-0VA 3749 ,IQBS,ITEADDRESS 41 1‘I0I41, M1Q. .Aeq. (Alf•»Dvfi1I OWNER'S NAME RIVLOnrd DobeiS P OJJW?ERADDRESSI 5a1119 I TEL SOS1lgill IS FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO0 FIXTURES 7 FLOOR-. 165M 11 2 3 4 5 6 7 8 9 10 _ 11 1 12 13 14 BATHTUB . CROSS CONNECTION DEVICEr _ DEDICATED SPECIAL WASTE SYSTEMjar _ L �_ DEDICATED GASIOWSAND SYSTEM DEDICATED GREASE SYSTEM _ _ t DEDICATED GRAY WATER SYSTEMli_ DEDICATED WATER RECYCLE SYSTEM , DISHWASHER DRINKING FOUNTAIN I I= __ _[_ FOOD DISPOSER FLOOR I AREA DRAIN _ INTERCEPTOR(INTERIOR) KITCHEN SINK ,. — LAVATORY ROOF DRAIN SHOWER STALL . SERVICE I MOP SINK TOILET URINAL n WASHING MACHINE CONNECTION „ WATER HEATER ALL TYPES -- WATER WATER PIPING > OTHER r INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑+ NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑+ OTHERTYPEOF INDEMNITY ❑ BOND❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the C.-: 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 • I hereby certify that all of the details and Information I have submitted or entered regarding this application are tru and 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 comp nce with all Pertinent provision of the '^ Massachusetts State Plumbing Code and Chapter 142 of the General Laws. V l Q PLUMBER'S NAME STEPHEN A.WINSLOW (LICENSE# 12298 SIGNATURE LJ MPQ JP❑ CORPORATION❑+ # 3281C PARTNERSHIP❑# LLC❑# et fet COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 18 REARDON CIRCLE O' er dil,. 1 CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 1508-394-7778 CL FAX 508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com I • `O\ a in. •-.vu.,,wu.r..was.J aawuatnasn o,.. _w— Department of Industrial Accidents 4.,–.}.., ii 11 ='1 -_It Office of Investigations 600 Washington Street: 47 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): EC.Wtrx51O YIUAM° a %t0-il . Ce, 1!1(, Address: 3Q.eoclwl Circle_ d City/State/Zip: SoA+n `fcrt-c„,k-, t4P- Phone#: '53S- 399-717C ' Are you an employer?Check the appropriate box: Type of project(required): 41 am a employer with 70 4. 0 I am a general contractor and I 6. 9 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. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. ❑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' 13.0 Other comp. insurance required.] my applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. • lomeowners 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. min an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. surance Company Name: Arm...)i Nu 1ueJ 21 f n to_ Cm, icy rlicy#or Self-ins.Lic.#: S a 1 lar • '1 Expiration Date: ‘-1 — Dot9 b Site Address: 3 �rhcsn Jt -t�-t1 ,k Q1 CFeg i4• t'1l7U City/State/Zip: Oar4(e7 ttach a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). dlure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a le 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 for insura overage vert a•on. to hereby certify un a e alms a penalties o p,jury that the information provided above is true and correct •natuT:: Date: tai 3l 1 awl- tone#: S'I)g:31`1. 777g 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): ' Z i ,� 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector r\ ' r' 6.Other Contact Person: Phone#: ' ' k