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Home My WebLink AboutBld-20-002194 w R MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ti ?) CITY `fafm 00/IA MA DATE Il)/HO//q 1 PERMIT#00-D/'-�02 R/� JOBSITE ADDRESS C Oink 5S 134 5, Yairnod i-il OWNER'S NAME Frank Marl P OWNER ADDRESS SUrdh-a TELISO S 3419 on IFAXI 1 TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUC NAL ❑ RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES❑ NOD FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 8 I 9 10 --11 --42 13_.. .14_.. _BATHTUBIIIIII ma MIMI CROSS CONNECTION DEVICE OR — iiii- DEDICATED SPECIAL WASTE SYSTEM - ' DEDICATED GAS/OILISAND SYSTEM -m-mosw. - _ _ DEDICATED GREASE SYSTEM DEDICATED'GRAY WATER SYSTEM _ ice --- ---,.-- i mall DEDICATED WATER RECYCLE SYSTEM r _ _- as ' _ -— -4 DISHWASHER - --- -- -- DRINKING FOUNTAIN FOOD DISPOSER _11.111111 — FLOOR I AREA DRAIN • -- --- -— INTERCEPTOR(INTERIOR) .,,.' — _ KITCHEN SINK -- —iirk--• . — " LAVATORY ROOF DRAIN __ _ •_ — — ..�..,�--- --, SHOWER STALL - -- - - SERVICE I MOP SINK TOILET URINAL __ - �—..-- - - -- -�__ WASHING MACHINE CONNECTION -- WNW -- _, - ---- �_=- -_ a WATER HEATER ALL TYPES IMP=WATER -—- PIPING MOM OTHER — ^- MOM -- ... INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tr 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 co ance with all Pertinent provision of the `O Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I STEPHEN A.WINSLOW _ 'LICENSE#112298 SIG I TURE MPQ JP❑ CORPORATIOND]#I3281C JPARTNERSHIPQ#NNW LLC '-- =- COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS l8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA - ZIP 02664 TEL 1 508-394-7778 J Q-- FAX 508-394-8256 CELL N/A EMAIL I accountapay'able(�efivinslow.com __ - -__ _ 'l • lk The Commonwealth of Massachusetts t a t, Department of Industrial Accidents lM 1 Congress Street,Suite 100 ,1 4 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE 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?Cheek the appropriate box: Type of project(required): 1.0 I am a employer with$8 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof 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.Lice#: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 -,,,-i3 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 a pai s lid pen lties of perjury that the information provided above is true and correct. N o Signature: - 'a"K,„ Date: 508-394-7778 Phone#: N Official use only. Do not write in this area,to be completed by city or town official. \ S 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#: