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� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
try •_-r, CITY r/i�/_'r/iy- / IMA DATE I.U� I a PERMIT# P111— 7
JOBSITE ADDRESS 16v 4 L'�/f/� ar
I OWNER'S NAME tarl�lnigraiS/J��T411.111111
P OWNERADDRESS I . .' Y /' J TEL ffhawe
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TYPE OR OCCUPANCY TYPE COMMERCIAL El ' EDUC NAL ❑ RESIDENTIAL i
PRINT '
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED YES 1:1 NO
FIXTURES 1 FLOOR-• I BSM t .2 I 3 14 I 5 1 8 1 7 j 8 9 I 1g I ti j t2 J 17 J 14
BATHTUB
CROSS CONNECTION DEVICE '
XDEDICATED SPECIAL WASTE SYSTEM
r� DEDICATED GAS/OILISAND SYSTEM •
'`J DEDICATED GREASE SYSTEM
`t, DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER . .
DRINKING FOUNTAIN
FOOD DISPOSER 1 '
FLOOR/AREA DRAIN '
INTERCEPTOR(INTERIOR) r A
KITCHEN SINK
LAVATORY
ROOF DRAIN _
SHOWER STALL
SERVICE/MOP SINK 1 • .
TOILET . . .
URINAL
WASHING MACHINE CONNECTION •
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•
OTHER , FFIc2V Ys
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G�iYrS ''' INSURANCE COVERAGE:
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oliey or Its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO cl
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW }• "'
LIABILITY INSURANCE POUCY 0 OTHER TYPE OF INDEMNITY 0 BOND❑ .
OWNER'S INSURANCE WAIVER:I am aware that the licensee sloes 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 E ONLY,0 ' ' El AGES .
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this applcaton are true an to loth best of my k • ge
and that aU plumbing work and Installations performed under the permit Issued foriNs application will •- In compliance wi U Perti nt provision •re
Massachusetts State Plumbing Cods and Chapter 142 of the General Laws. Ls
PLUMBER'S NAMEI STEPHEN A WINSLOW LICENSE# 12298 SIGNATURE
MP0 JP CORPORATIOND#13281 IPARTNERSHIP❑# LLCQ#I 1
COMPANY NAME I E.F.WINSLOW PLUMBING&HEATING CCS ADDRESS 8 REARDON CIRCLE
TYI SOUTH YARMOUTH I STATE I MA I ZIP 102664 I TEL 1508.394.7778
aryl 'r
FAX 1508.394.8258 I CELL I 'EMAIL I ACCOUNTSPAYABLE@EFWINSLOW.COM •i I
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The Commonwealth of Massachusetts
=it — Department of Industrial Accidents
P.= i= .t Office of Investigations
=4'411-y 1 Congress Street,Suite 100
=_i'zic a Boston,MA 02114-2017
:I'll...SO, wwwmass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): E.F. WINSLOW PLUMBING & HEATING CO.,INC.
Address:8 REARDON CIRCLE
City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-3944778
Are you an employer? Check the appropriate box: Type of project(required):
1.0 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. 0 Building addition
[No workers' comp. insurance comp.insurance.:
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 MGL 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
] employees. [No workers' 13.0 Other
.• comp.insurance required.]
i 'Any applicant that checks box 01 must also fdl out the section below showing their workers'compensation policy information.
t Homeowner 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 sub-contractors 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.Lie.#: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 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 certify un p ins and p alties of perjury that the information provided above is true and correct
/ Date:2014 •
phone#: 508-394-777 '
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#: