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HomeMy WebLinkAboutBLDP-20-001197 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK MA DATE r .2.1 /4 PERMIT# ��_;.�_) CITY I Yam? au 4-in - I _. JOBSITE ADDRESS Iq CanSi",i.n hi���linaii/fi d2.673 OWNER'S NAM iV16f t°N fAl a --- - - - - p OWNER ADDRESS Lace I. New Ya/ Y TE 56g17 S! FAX )00 1 EDUCATIONAL 0 RESIDENTIAL© TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT PLANS SUBMITTED: YES® NODCLEARLY NEW:® RENOVATION:© REPLACEMENT:® FIXTURES Z FLOOR-4 esM 1 2 3 4 5 6 7 8 9 19 - -11 42 13. 14___ BATHTUB IIMMIan MI N CROSS CONNECTION DEVICES MI NM MN MI NM MI IIIIIII_ MI_ ISM M ' iMMI� - , DEDICATED SPECIAL WASTE SYSTEM ==- -_ M 1 0 M M O NM DEDICATED GASIOILISAND SYSTEM Ilm mg u- DEDICATED GREASE SYSTEM MI MIN MN MN ---0.111.1110110111110.111-1.111•11 INN MIN MO NM MI11-1011.11111111111 MON MI MI DEDICATED'GRAY WATER SYSTEM . MI ME OM nil I 1 1111.11111_DEDICATED WATER RECYCLE SYSTEM NM 11.11 MN NS riillilli1111 -1-1 MI Nil,IIMI MI MI MI ----DISHWASHER----- --- - -- ,-- DRINKING FOUNTAIN - - - FOOD DISPOSER _ FLOOR;AREADR�,IN ( — - - -- _ INTERCEPTOR(INTERIOR) OM MN U KITCHEN SINK liil = _ - -- LAVATORY .1111111 OM MN MIN -111111111111111M111111.111.11- — - ROOF DRAIN MI OM an NMI 111.111M111111.1111111111111 MIR MI NM MA OM MI SHOWER STALL NM Min MN MN IIIIIIPMANO-111111111111M111 MN PPM NMI MI MN Nei - SERVICE 1 MOP SINK �En MI Mil 111111111111111.11110111.1111111111=- MI INN MNU.MI MIN TOILET NMMIIM - _ OW Ail MN MI NM URINAL �MNM NMI; MI WASHING MACHINE CONNECTIO NM NME gm gm-=mimmimmommom illill MIN MN NM NI MI WATERHEATER ALL TYPES NM IIIIIIII INN MN IIIILMIIIIPIIMIAIIIIIIIIIIMIIIIIIIIIIIVIIIIIIIII NM NM MI MN WATER PIPING ilii iliiil MI 111111111111 PM MI Mil MI OTHER __ 'MM_ � MIIMONM Ian I MN —M:m:nu oillinatimillmon mama mom win vim um INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE 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 ® AGENT El SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application a- rue 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 o pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. o PLUMBER'S NAME I STEPHEN A.WINSLOW __ LICENSE# 12298 SIGNATURE ' MPQ JP CORPORATIOND#I3281C IPARTNERSHIP04 LLCEN WWI ITN COMPANY NAME EF WINSLOW PLUMBING&HEATING l ADDRESS'8 REARDON CIRCLE 1 Siz.r4 CITY'SOUTH YARMOUTH 'STATE MA ZIP 102664 1 TELL 508-394-7778 - 1 s FAX 1508-394-8256 1 CELLI N/A I EMAIL I accountspay able nefwinslow com 2 4961 • The Commonwealth of Massachusetts , Department of Industrial Accidents 1 1 Congress Street,Suite 100 „ Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH fHL+ PERMITTING AUTHORITY. 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#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 88 employees(full and/or part-time).* 7. 0 New construction 2.EI I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ['Demolition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.El Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOF repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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. tContractors 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 sub-contractors 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.#:1909A Expiration Date:01/01/2020 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 MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and e pai ss nd pen !ties of perjury that the information provided above is true and correct. Signature: 4' ,��,, Date: Phone#:508-394-7778 Official use only. Do not write in this area,to be completed by city or town official 1� O' 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#: