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Bldp-20-002769 3 1 A ,f; , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ,_... QGI_ Slm_11L!!7 ,�,... MA DATE j-' '%�' . PERMIT#n' I-a°�0-G'�I,' 7�0/�' JOBSITE ADDRESS 16 S(.0 vie- _..0 ve- .,_ ,..,_I OWNER'S NAME C L[s s /LS -.n ..w POWNER ADDRESS 2-0.._-5, ✓n/o / ��V 61 27?akl)+/ TEL S 7 7 T FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ED EDUCATIONAL Ej RESIDENTIAL PRINT CLEARLY NEW:U RENOVATION:E, REPLACEMENT:>7,4 PLANS SUBMITTED: YES El NO[] FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 4 , CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM MilligatillialtiftS slitiolt INS 11.11111101,11 nil WWII MOM DEDICATED GAS/OIL/SAND SYSTEM WWI 11011111111111111111111111111111.1110j[� 1IIIIIIIIIIII IOW 111111001 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 1 ilink MI II " " r DISHWASHER _._._. .� _ .; : T,. DRINKING FOUNTAIN 1r` FOOD DISPOSER i I _ I FLOOR/AREA DRAIN � � � A INTERCEPTOR(INTERIOR) =1 - KITCHEN SINK zLAVATORY ROOF DRAIN _ .._ z� .,-_ SHOWER STALL �,. _ -~ 9� if . .:. _.i�. :- r SERVICE I MOP SINK w l L 1 TOILET rf URINAL i �� 7061_ .___ 'C WASHING MACHINE CONNECTION I r ,� 1ant a� WATER HEATER ALL TYPES CLI Sr gr WATER PIPING �., 1__ 1111110011"=4111111111146111111.111.111111111111 MINIIIIIIIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIWIMMIalmt annamtait MOM MN 111110.11111111111111111111111111111111111111111101111.1111110110WILIWINIIIIIIIIIIIIIII_ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESED NO I aCI IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY[J OTHER TYPE OF INDEMNITY D BOND U 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 certify that all of the details and information I have submitted or entered regarding this application ar true 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 mpliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I STEPHEN A.WINSLOW t LICENSE# 12298 SIGNATURE MP[J JP 0 CORPORATION II v J# 3281 C PARTNERSHIP,#L M p 1 LLC L # COMPANY NAME, E F WINSLOW PLUMBING K HEATING ADDRESS 18 REARDON CIRCLE CITY SOUTH YARMOUTH _J STATE;KK M►A I ZIP 102664 ._p TEL 508-394-7778 FAX F08-394-8256 CELL I N/A J EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COMti� /j G- ►J The Commonwealth of Massachusetts )k ;'e/ l=4 Department of Industrial Accidents k..,.\--...„.....7:.:...: , __ ; 1 Congress Street,Suite 100 ' ��_ Boston,MA 02114-2017 `( .Y"�#+„,s< iwvw.mass gov/dia ' \ Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Analicant Information Please Print Legibly Name(Business/Organization/individual):E.F.WINSLOW PLUMBING&HEATING CO., INC y Address:8 REARDONCIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:508-394-7778 \ Are you an employer?Check the appropriate box: - 1 d): —i.©f am e a •tuycr will,88 - employees(full and/or part-time).* Type of project(require 7. New construction ) 2.01 am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. Remodeling 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9 0 Demolition 4.0 tam a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hirred the sub-contractors listed on the attached sheet. 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t ]3.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,i((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. 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.. 152,§25A-is-a criminal violation punishable by a fine up to S 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 S250.00 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 wtd to pal slnd pen hies of perjury that the information provided above is true and correct Signature: 3' ..r 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#: