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Home My WebLink AboutBldp-20-003171 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUM;;ING WORK T_ = PERMIT#�✓�� (� - = �� I MA DATE -,v 1.�_ CITY I - -- cur _ OWNER'S NAME JOBSITE ADDRESS`t7 (i t..�. 10-u-:c r k�_. 1. _ _ IIIIII P OWNER ADDRESS 6 t51 .L - TELIZIM FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIALEY PRINT PLANS SUBMITTED: YES El NOD CLEARLY NEW:ElRENOVATION:a REPLACEMENT:El FIXTURES-1 FLOOR—i BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB lini No mai um Om=um ism on um ton um OR C -- � Mil MAWMNM NM ED CONNECTIONSL DEVICETEOM N MNMOM MM UN U OM MO N,- I DEDICATED SPECIAL WASTE SYSTEM �� , NM NM DEDICATED GASIOILISAND SYSTEM OM11M NMMINI _ UN UM MI MI t/l DEDICATED GREASE SYSTEM n®MI W NM IMO MM.NM Mill U an GRAY WATER SYSTEM111111111111111.1111111111.11.11111.10.11.11111 IJ MOS DEDICATED �� NM� DEDICATED WATER RECYCLE SYSTEM mom pm ��.: UNUNMU - -- DISHWASHER —_ �-- --ON _-_ • MUM MMUNU MN NM DRINKING FOUNTAIN �� ii.�,� _ UI�NMUNM NI FOOD DISPOSER J� �' IMI NM n 1AREA SIN MN FLO.,P., �R MIU- — K INTERCEPTOR(INTERIOR) �'' M. I MO NO KITCHEN SINK ��-� M LAVATORY I ----_ - __- MI' -3 ROOF DRAIN = iiii MOM NM iliN WOMMINgliggin MN MI 0.11.NM C ®� On UM �� SHOWER STALL ',UN UN UN SERVICE I MOP SINK MN M.NM OM-_ - �� TOILET NN MiNMi MN URINAL NN — -- WASHING MACHINE CONNECTION - - U NM gingagning1001.1111 ON MIN NI M. WATER HEATER ALL TYPESMal tilrlii NM NM®NM in lini NM NM MN NM _ WATER PIPING gig sui - -__ ® 1 OTHER 'w 2r_1�lci.n —i-- 01 A IIIINE in _ u an um ma -10111.1.111111.1.11411MMI INSURANCE.._._. UM ' COVERAGE: El I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 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 El 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 I hereby all plumbing rthe details and information I have d installations performed under the submitted pe permit issuedr for this applicationg this n will bein are co/pliance with all Pertinent prow s on of the knowledgeand that all p g (i/„L4 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��u�_: , PLUMBERS NAME STEPHEN A.WINSLOW __J_..n — _- LICENSE# 12298 _- , SIGNATURE MPD JP® CORPORATION D#I3281C 1 PARTNERSHIPO#1=2 LLC0 COMPANY NAMELEF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE CITY`SOUTH YARMOUTH !STATE MA ZIP 1.216.1________I TEL 508-394-7778 FAX 1508-394-8256 1 CELLI NIA 1 EMAIL accountspa able,_efwinslow.com The Commonwealth of Massachusetts l� !, Department of Industrial Accidents =;:n1= 1 Congress Street,Suite 100 __ �=Q' Boston,MA 02114-2017 s ' www mass.gov/dia t� v Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. V TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly �C E.F.WINSLOW PLUMBING &HEATING CO., INC \� Name(Business/Organization/Individual): 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-empleyersuiih 88_ employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working forme in $. Ej Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 Q Building addition 4.❑I 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 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.Q 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. (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 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 a pai s nd pen lties of perjury that the information provided above is true and correct. Signature: �° ' �/ Date: Phone#:508-394-7778 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#: