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Home My WebLink AboutBLDP-15-003090 - r _ ✓ `°',' ....- 'e 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ;.� w,,=• r. /1 On —:�_ IMA DATE( /0 '//'/�f (PERMIT# 6Wo,(4 SO90 _x;1;1- • awl a rmoil t"h / JOBSITE ADDRESS 1 /9 7/1• h'/ 0-'72-VI OWNER'S NAME( l/0/C40/IJ P OWNER ADDRESS 11j}pSi iM 024>1/21M I TEL[,5 7j'/., FAX, ( TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:C:1 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 N0/CV FIXTURES 1 FLOOR-6 BSM 1 1 J .2 4 3 4 J 5 6 1 7 I 6 I 9 J 10 .111 I 12 I 13 J 14 _ On BATHTUB C' CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM ZlIDEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 41wr v r i DISHWASHER J DRINKING FOUNTAIN I -4 1 ' , FOOD DISPOSER _ a FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) I , KITCHEN SINK LAVATORY 6 , , i ROOF DRAIN r SHOWER STALL SERVICE I MOP SINK Ne e TOILET . . URINAL WASHING MACHINE CONNECTION • WATER HEATER ALL TYPES , - t � , WATER PIPIN _ I • v OTHER I v 1 9 1 1 1. ____•__ _ _ t INSURANCE COVERAGE: I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES O NO [1i IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW *• UABIUTY INSURANCE POLICY O OTHER TYPE OF INDEMNITY 0 BOND❑ . OWNER'S INSURANCE WAIVER:lam 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 AG . 0 . SIGNATURE OF OWNER OR AGENT Thereby certlly that all of the details and information I have submitted or entered regarding this application are •- ante rate tot e best of m • edge and that all plumbing work and installations performed under the permit Issued for this application will be in compile - II Pe rant previal. • e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `. �` PLUMBER'S NAME I STEPHEN A WINSLOW I L LICENSE#112298 I SIGNATURE MPO JP • CORPORATIONO#13281 (PARTNERSHIP❑#I ILLCD#I 1 COMPANY NAME(E.F.WINSLOW PLUMBING&HEATING CCd ADDRESS(8 REARDON CIRCLE „ I Y CITY'.SOUTH YARMOUTH I STATE MA ZIP 102664 1 TEL 1508-394.7778 P FAX 1508-394.8258 1 CELL 1 1 EMAIL (ACCOUNTSPAYABLE@EFWINSLOW.COM •i• I/ rig 14 / i The Commonwealth of Massachusetts - w Department oflndustrialAccidents t =:=1�i- t Office of Investigations l e, _II _ei-y 1 Congress Street,Suite 100 • Boston,MA 02114-2017 '''."w www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(easiness/Organtzat;on/[naividaal): 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: Type of project(required): I.❑� I am a employer with 66 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).*' - - have hired the sub-contractors . 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8, 0 Demolition working for me in any capacity. employees and have workers' 9. Buildingaddition [No workers' comp. insurance comp.insurance.: 0 required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions '3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MOL 12.0 Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. , — I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic.#: 1764A Expiration Date:01/01/2015 Job Site Address: City/State/Zip: 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 MGLc. 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 certify un p ins and p aides ofperjury that the information provided above is true and correct Signature: / , / Dat e•2014 • Phone#: 508-394-777 t��///�w//«"!.._. 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone II: