The URL can be used to link to this page

Home My WebLink AboutBLDP-20-001499 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �_ �- MA DATE _: CITYI l�oovi ^_I PERMIT# Pi0—a9/he,' JOBSITE ADDRESS PIS Ofc i c)In 1,1454- f/MO(.lt I OWNER'S NAME (-hif 5 AA /e OWNER ADDRESS 0 13o I iu l 5a,� (n 1(di OVM4 az614 I TE 0'gb1345 FAX P TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIALIEr— PRINT PLANS SUBMITTED: YES NOD CLEARLY NEW:ElRENOVATION:D REPLACEMENT:D� 5 6 ®v 9 19 �� FIXTURES 1 FLOOR- at� IiMMOMI1•MOAOOM M� 111011 BATHTUB OM CROSS CONNECTION DEVICE P.M _ DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GASIOILISAND SYSTEM OM M M IM - Na U II N MI DEDICATED GREASE SYSTEM M N NM OM PM M _ II OM MOM I�UMRMII MP MA MI DEDICATED'GRAY WATER SYSTEM MI�OM�., DEDICATED WATER RECYCLE SYSTEM an MI OM MR OM OM NA OM NM�U MI M U U DRINKING FOUNTAIN NM_Mel nil MN - MU WW1 IM I1.11 111111 DISPOSER OM iiilli iM IiNMI NMFOOD - _ P MN FLOOR/AREA DRAIN' iiiii lil- 1 _ Om N OMR KITCHENPINK(INTERIOR) NM MN PM_NM iiili MN Oil MI��UM �II�� LAVATORY MI ROOF DRAIN —_N_PM-in-M SHOWER STALL OM iiii IMO Iiiii iiiii N_MN MI UP'UPI 1.111 MA MI SERVICE/MOP SINK INN Mai alii in iiii NM `NMNMU 1111111 TOILETilli �� NM MIMI MI MI OM NMI NM 1.1101111M.MN iiiiP OM URINAL NM anMg� INMI 'UOM . WASHING MACHINE CONNECTION lin NM NE Mg N N- 1111111 MI X'MI MIOMR NMI NM NM WATER HEATER ALL TYPES Mil ME NMI M MN IIIIII MR-MI 1111.1111.MA — WATER PIPING MI MillIMP OM IMP OnNMMPMOMPMMR OTHER - lila iiii NM lill MI Mil Oil NM NM NM NM ME OM NM OM 11111111111.1111-11.111.111111111111.MN Mill 1111111 MN 11111 MN MN MN MN MN MN NM MI NM NM 11111111.11.11111111.1111111.1111111111 MN OMR NM IMP IIIMI MN WWI UM MN MN MIIIIIII MN MO MP MI INSURANCE COVERAGE: 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® BOND ID 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 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru 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 com nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \/'1 PLUMBER'S NAME;STEPHEN A.WINSLOW __ 'LICENSE#112298 I ��SI AT R feler�� MPD JPD CORPORATIOND#13281C IPARTNERSHIPD#1 1LLC ,n ts— COMPANY NAMEI EF WINSLOW PLUMBING&HEATING 1 ADDRESS 18 REARDON CIRCLE 1 c4 CITY'SOUTH YARMOUTH I STATE MA ZIP 102664 1 TEL 1508-394-7778 ' __1 _ FAX 1508-394-8256 1 CELLI N/A 1 EMAIL accounts payable efwinslow com The Commonwealth of Massachusetts LTrwerV,W!1, Department of Industrial Accidents _eiiifi,.� 1 Congress Street,Suite 100 =1114_4 Boston,MA 02114-2017 54 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH 1'Hl,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): l.❑✓ I am a employer with 88 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. ❑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 10❑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.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.17I 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.$ 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. 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 pars nd pen Ities 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#: