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HomeMy WebLinkAboutP-18-5695 - • • a, MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK CITY ILI NI U W S MA DATE!c /`//8 I PERMIT# S l. •396- p e=r / I�. r N • A JOBSITEADDRESS a CDGFf -5 j OWNER'S NAME r --- , I OWNERADDRESSI 6404E-- 1 TELIS: 4'76.7/ FAX TYPE TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL £3 RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT:[ 2,L PLANS SUBMITTED: YES® NOD FIXTURES 1 FLOOR-+ D0©©©©0©00 to 1011113113101 7777111-r7)17&vicE sisaretsllsl sans DEDICATED SPECIAL WASTE SYSTEMaIOMMSM ' DEDICATED GASIOILISAND SYSTEM IMMIrWrW WK DEDICATED GREASE SYSTEM i l DEDICATED GRAMFSIIINEMIWWIIIIOIMOOOISFS DEDICATED WATER RECYCLE SYSTEM � � tapposioS �� � � DISHWASHER Y WATERSYSTEM WilialailK _ I�� �nr r DRINKING FOUNTAIN Ma ` i -_ 1111. ea SVIMPSIOISSIMINSTIM FOOD DISPOSER .11 11011.11,111101101101101.:01011INVONWIMMUNI `c jirRboROMOSTISSINA SISST M_ I � I _ LAVATORY ala4� ar SHOWER STALL ROOF DRAIN Me r- SERVICEI MOP SINK ISliaSOKINITIallitilittilltta IIIICESISIMMISPIATWOIMIalaaM.Palanillt �' M�'�antillallair r- � 0 -� WASHINGMACHINE CONNECTION W ealeaSSES. Ann•mm ISITIONIMISIIII1011110111111111011111101111fianiTieltill ,......-C. . . SIVA Iil�l#IA r10 11 —MI OTHER -, _ -_ Ss . -7--------assississurnamorsonstesom-anutoottputsousts ---.). ' '''•••"."'-. 'L - SIONIONSIONOSISIS1001111111.10611011001NOIN c'11 INSURANCE COVERAGE: Ihave acurrent llabili Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 1YES 0 NO J IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW tiO LIABILITY INSURANCE POUCY Ell OTHERTYPEOFloamy® BOND® C 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 and that all pluthat all of the details and Information I mbing work and Installationsperformed hunder the permit Issued for this applicaave submitted or entered regarding itios npwilrlbe In corn lance with all Pertion are trui and accurate totinent t provision of the Massachusetts State Plumbing Cede and Chapter 142 of the General Laws. , .1i 1 i PLUMBER'S NAMELSTEPHEN A.WINSLOW 1LICENSE#112298 S 'TU- • MPI: JP® CORPORATION 0# 3281C _ PARTNERSHIP®#a LLCDC= COMPANY NAME'EF WINSLOW PLUMBING&HEATING i ADDRESS 8 REARDON CIRCLE STATE MA ZIP 02664 TEL 508-394-7778 CITY SOUTH YARMOUTH comlow EMAIL accountss.abl able efwins . FAX 508-394.8256 CELL�NIA � - - __ _ N\ -J , 1 _ The Commonwealth of Massachusetts =1-rp= t Department oflndusirialAccidents ..,wig- 9 1 Congress Street,Suite 100 Boston,Ml 02119_2017 Workers' WWW.maSS.gov/diR ^ t*� Compensation Insurance Affidavit:General Businesses. • \ \ �\ TO BB FILED AselicantInformation WT�T�FERhdIT17NGAUTEOgITX. yyl\` • Please Print Le 'bl• Business/Organization Name:E.F.WINSLOW PLUMBING&HEATING CO.,INC INAddress:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH,MA 02684, phone At;598394-7778 Are you an employer?Check the appropriate box: • 1. ✓C3 I am a employer with�_ - d ' Business Type(requ red): �— or part-time). employees(full and/ 5• []Retailts:\ 2,® I am a sole proprietor or 6. QRestaurant/Bar/Eat n • P P partnership and have no g Establishment \/ employees working for me in any capacity. 7. []Office and/or Sales(Incl.real estate,auto,etc.) -�I [No workers'comp.insurance required] 8. 0 Non-prom 0 3.❑ We are a corporation and its officers have exercised their right of exemption per c.152,§1(4), 9. ❑Entertannrent no employees.[No workers'com •insurance wehredave 10 Q Manufacturing 4.❑ We are a non-profit or P insuranceoluntee s P organization,staffed by volunteers, 11',..gHealth('are with no employees.[No workers'comp.insurance req.] 12.❑Other *Any applicant that checkshave box#1 must also fill out the section below showing their workers'compensation policy information. organization corporate houofficers box themselves,but the corpomtion hes other employees,aworkers'compensation policy is organization should check haz#]. !" cy required and such an I am an employer that'se: prnnorkers compensation insurance for my employees. Delay's the policy information, MUTUAL INSURANCE COMPANY Insurance Company Name:ARROW Insurer's Address:23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL,MA 02467 Policy#or Self-ins.Li;#1821A Expiration Date:01/01/201 _ Attach a copy of the workers'compensation policy declaration page(showing the policynumb er and expiration date). e� Failure to secure coverage as required under Section 25A ofMGL c.152 can leadto the imposition of criminal penalties of a he up to$1,500.00 and/or one-year imprisonment as well as civil penalties in the farm oh a STOP WORT{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 cern " ' ena[ties o perjury that the information provided above is Eros and correct Si_ alum: _ • 'hone#:508-394.7778 Date: Official use only. Da not write In this area,to be completed by civ or town official • \� (.Sty or Town: yl Issuing Authority(cirdeone): Permff/Iicease# \\\�S\ 1.Boardhof Health 2.BuildngDeparhnent3,CtytPuwnClerk 4.LlcensingBoardS.SeIectmen'sOffieeO 6.Other �Cantt............ .2' act]?erson: Phone#: U, www.mass.gowdia tom_