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HomeMy WebLinkAboutP-18-4557 7.— MASSACHUSETTS UNIFORM APPLICATION FORA MIT TO PERFORM PLUMBING WORK P CITY 0101t f f3cr-.ST j MA LDATE 2 7 U.__ PERMIT# /9/P g 7 ccd J0BSITEADDRESS th ( at,e, P6-T IOWNER'S NAME N � ) P OWNER ADDRESS I 5474e-- I TELL • a-__I IFAXI I TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIAL PRINT �tit!a/`' L PLANS SUBMITTED: YES® NOD NEW: RENOVATION: REPLACEMENT:® 1 Lwriv -r BSM 1 2 3 4 5- 6-I 7 8 9T 16 13 14 FIXTURES? FLOOR _{ BATHTUB _ t _ 7_771 .__ 1 I_-,. I �. >�..y- _- { - CROSS CONNECTION DEVICE `I__ M • .., DEDICATED SPECIAL WASTE SYSTEM _ q DEDICATED GASIOWSANDSYSTEM —1C I — DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM —17-i I _I 1I '�`� I _� DEDICATED WATER RECYCLE SYSTEM f II I - r Id l I _ . ' I, • f ' -D . DISHWASHER E FOOD DISPOSER FOUNTAIN . I h 1 . ' FOOD DISPOSER I I I _ FLOORIAREA DRAIN .. 1 I _ INTERCEPTOR(INTERIOR) r-'� r s = I 1". I- F- fi if KITCHEN SINK =LAVATORY ROOF DRAIN ±'.-± 1 -: it:! $ E3t ' _ -- • SHOWER STALL SERVICE/MOP SINK i TOILET l tla . ' URINAL -- – � - – WASHING MACHINE CONNECTION1 I_ �- WATERHEATERALLTYPES I r_ �r !l C WATER PIPING II t :i�ry t� fi., . a^ �._i.I . n u.1 p� OTHER L 11. - r l_ [ l---&-is- C • ail- ',_ r 9 a I i ,H.L.. [ I -� Imm_ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ENO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW t e. LIABILITY INSURANCE POLICY 0+ OTHERTYPE 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 0 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 tru-and accurate to the best of my knowledge and that all plumbing work end Installations performed under the permit Issued for this application will be In corn.i. ce with all Pertinent provision of the Massachusetts State Plumbing Code end Chapter 142 of the General Laws. `_n. ;tt/ PLUMBER'S NAMESTEPHEN A.WINSLOW ,LICENSE# 12298 SIGNATURE MPlp JP® CORPORATION 0# 3281C _.-iPARTNERSHIP®# LLCD# alli COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE QQ CITY!SOUTH YARMOUTH 'STATE MA ZIP I02664 8 TEL 1 2B-394-77.78 ! FAX 508-394-8256 i CELL INIA t EMAIL Iaccountspayablea©efwinslow.com 1 - � MI6 �3 N . A I ewe The Commonwealth of Massachusetts It Department ofIndustrial Accidents •t V(f_ I Congress Street,Suite 100 �, -- Boston,MA 02114-2017 `\ --;. • y 'i.1a I www.mass.gov/dia Workers'Compensation Insurance Affidavit:general Businesses. TO BE FILED WITH TAE PERMITTING AUTHORITY. A a a licant Information 1.1 Please Print Lelib! Business/Organization Name:E. F.WINSLOW PLUMBING&HEATING CO.,INC IR3 \ Address:8 REARDON CIRCLE ` QN City/State/Zip.SOUTH YARMOUTH,MA 02664, Phone#:508394-7778 Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with _I-S L_employees(full and/ ' 5. 0 Retail �p or part-time).* 2.0 I am a sole proprietor or partnership and have no 6. ❑Restaurant/Bar/Eatmg Establishment ' 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 ": ..; no employees.[No workers'comp.insurance required]** 10.0 Manufacturing 4.0 We are a non-profit organization,staffed by volunteers, 11.0 Health Care T? with no employees.[No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box#1 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#1. 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 •y``' City/State/Zip: CHESTNUT HILL,MA 02467 I` Policy#or Self-ins.Lic.#1821AE �v Attach a copy of the workers'compensation policy declaration page(showing the policy ionDnumber 0and expiration date). y� Failure to secure coverage as required under Section 25A of MOL c.152 can lead to the imposition of criminal penalties of a �\\ I\ 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 J 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., Ido hereby cert- ,• . ,, , ,enalties o perjury that the information provided above Is true and correct ` i Si_nature: L 3 I r / 4 , c....#•.•� Date: .hone Ai;508-394-7778 Official use only. Do not write in this area,to be completed by city or town official • Nl- City or Town: Issuing Authority(circle one): Permit/License icense# 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 ••