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HomeMy WebLinkAboutP-19-1818MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE I PERMIT # /✓f %iP i-LOO /g JOBSITE ADDRESS 1237 AA R 0g, OWNER'S NAME q — P OWNER ADDRESS E WIT qO5 TEL D SIoS' FAX TYPE OR OCCUPANCYTYPE COMMERCIAL ❑ EDUCATIONAL © RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: El REPLACEMENT:a PLANS SUBMITTED: YES[:] NOQ FIXTURES 7 FLOOR-- BSM 1 1 2 1 3 4 5 1 6 1 7 8 9 1 10 11 12 1 13 1 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED'GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabilitV nsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Q NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECKONEONLY: OWNER ❑ AGENT ❑ 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 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 lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.1�^: PLUMBER'S NAME I STEPHEN A.WINSLOW JLICENSE# 12298 SIGNATUREc� MP❑+ JP❑ CORPORATIONO# 3281C PARTNERSHIP❑#=LLC❑#® COMPANY NAME I EF WINSLOW PLUMBING & HEATING ADDRESS FIREARDON CIRCLE CITY F70UT11 YARMOUTH STATE= ZIP 102664 TEL 508-394-7778 FAX 508 394 8256 CELL NIA EMAIL accounts a able efwinslow.com M)_\ llf4 VVIIfIIWIf /Y f.Nif/f f tI1NJJNi./f NJYµJ Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeib� Name City/State/Zip:�o s `/en r, ,�, 14 Phone #: e503.22A4 17715 n employer? Check the appropriate box: '%O Type of project (required): a employer with 15a 4. ElI am a general contractor and I 6. ElNew construction oyees (full and/or part-time).* sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. _ 7• ❑ Remodeling ship and have no employees These sub -contractors have S. ❑ Demolition working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition required.] i. E] I am a homeowner doing officers have exercised their 10-ElElectrical repairs or additions all work right of exemption per MGL ILEI Plumbing repairs or additions myself. [No workers' comp. C. 152, § 1(4), and we have no 12.❑ 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 f 6 1 Homeowners who submit this affidavit indicating they ae doing all work and then him outside contractors mW compensation ost submicy it n w 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 a employer oral is prov !formation. iding workers' compensation insurance for my employees. Below is the policy and job sue lsurance Company IM Name: _"%_J r'iQi 0LA olicy # or Self -ins. Lice ^#: M $ a I Pr IMI Expiration Date: -I aol� tb Site Address:�23 Cetelmo , s"J ib �t-e Q!9,atri._liY I City/State/Zip:_ O)N I67 ttach a copy of the workers' compensation policy declaration page (§howing the policy number and expiration date). rilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 t at a copy of this statement may be forwarded to the Office of .vestigations the DIA or insura� overage veri a on. do hereby certify an a airs a penalties o p jary that [he information provided above is true and correct. \ V natuT Date: ("0 I a0v tone #: g)l,114{ 7771 Official use only. Do not write in this area, to be completed by city, or towr: offieiaL City or Town: Permit/Licebse # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: M�