HomeMy WebLinkAboutP-19-2816 On-/I 0Vt^,A7-6<'V3
MASSACHUSETTS UNIFORM APPLICATION OR A PERMIT TO PERFORM PLUMBING WORK
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-'"�' CITY tlATwa MA DATE 10 -3\-lS PERMIT#4PF)Q-600/(O
JOBSITE ADDRESS S t (tewet42 �..a..,re_t+ce RD, 1 OWNER'S NAME Este Uar
P OWNER ADDRESS Skrn.e. TELierb'7'7y-122-OA3,5AFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 9 EDUCATIONAL 0 RESIDENTIAL Er
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:E PLANS SUBMITTED: YES 0 NO❑+
FIXTURES 1 FLOOR—, r BSM 1 2 1 3 4 5 6 7 8 9 10 11 12 ' 13 14
BATHTUB _ r f _
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CROSS CONNECTION DEVICE arV ( r
DEDICATED SPECIAL WASTE SYSTEM 1 I i 0 S i
DEDICATED GAS/OIUSAND SYSTEM an ma i_ J ;_ 1
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM 10
DISHWASHER
DRINKING FOUNTAIN I I ( _
FOOD DISPOSER
FLOOR/AREA DRAIN 1
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INTERCEPTOR(INTERIOR) 1
KITCHEN SINK
LAVATORY ii 1
ROOF DRAIN
SHOWER STALL 1
_
SERVICE I MOP SINK r
TOILET
-
URINAL -
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES / j
WATER PIPING
OTHER
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E] NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 9 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 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 com nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. a /ss�cCe
PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE •�i
MPD JP El CORPORATION0# 3281C PARTNERSHIP❑# LLC 0#
COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX [508-394-8256 CELL N/A EMAIL accountspayable@efwinslow.com
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66 Gie
The Commonwealth of Massachusetts
T=-- Department of Industrial Accidents
ITOI= 1 Congress Street,Suite 100
Boston,MA 02114-2017
t www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO., INC
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778
Are you an employer?Check the appropriate box: Business Type(required):
, 1.0 I am a employer with 10 employees(full and/ 5. 0 Retail
or part-time).* 6. 0 Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. 0 Non-profit
3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees.[No workers'comp.insurance required]**
11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees.[No workers'comp.insurance req.] 12.0 Other
*Any applicant that checks box MI must also fill out the section below showing their workers'compensation policy information.
"If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box MI..
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL, MA 02467
Policy#or Self-ins.Lic.#1821A Expiration Date:01/01/201
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine 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
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification..
I do hereby certi d c,f the aim and nalties o perjury that the information provided above is true and correct IF/
Signature: Y "` <ti— Date: /a /31 /12
phone#:508-394.7778 S
Official use only. Do not write In this area,to be completed by city or town official I\
City or Town: Permit/License# \�
Issuing Authority(circle one): -
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia