The URL can be used to link to this page

Home My WebLink AboutBLDP-20-000468 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK T e= MA DATE ; PERMIT# P a '-. ;II CITY; _Yol U+h _.___ __.�__ _ JOBSITE ADDRESS 1311 Rwkakilidizci,5Am,yafixai OWNER'S NAME 1 a e '_ e- _ oa6614 P OWNER ADDRESS II IS 5GbA1. ' �ve%_►� kl;P/d/AA 01535 ' TEL 0� •a1-4()a6 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT PLANS SUBMITTED: YES El NOD CLEARLY NEW:D RENOVATION:0 REPLACEMENT: FIXTURES 1. FLOOR--+ BSM 1 2 3 M© 6 Q0 9 10 m 12- BATHTUB - On_ [ R NA NM 111111_ _ , CROSS CONNECTION DEVICE AI®NE MI MA - NM NM DEDICATED SPECIAL WASTE SYSTEM MI MN NM poi ni US N�'U US DEDICATED GAS/OIL/SAND SYSTEM MN Ira um sigum mg impri0111.111'U U OM M NM DEDICATED GREASE SYSTEM OM aiii Mini MI-NMI-MI U U U I,U NM OM MS MR DEDICATED GRAY WATER SYSTEM �®��— ��r DEDICATED WATER RECYCLE SYSTEM MI I _ ® DISHWASHER - I I NM��- _ MAIM OM NM DRINKING FOUNTAIN NM INMNNM!INMMIN MIR FOOD DISPOSER � MI MI Mi.MN NU M-1,11111111 MI NM IIIIII VIM INN MI _MI NM UN an Nil imi ma ma mai ow Nei MI II FLOORAREA DRAIN �. INTERCEPTOR(INTERIOR) =n a am am amage am=um in wia an an IIIMI Wm ME NMI®MN US um MI AN US KITCHEN SINK _ NI MOM LAVATORY ��MI®MINIM. �MN�'�NM® ROOF DRAIN US SHOWER STALL ®M MI M IMN�' 1 NM SERVICE I MOP SINK MIR iliiii in NM IIIII In MO NM IIIIIII`U NM IMP�IUS MNONI MI NM MIMI� TOILET �-�� -- URINAL NM MI NS MIN NM NMI On MI MN MIN MI NM RIM MI MIN MI MI MI In NomaMI� EATER ALL TYPES MI N N MN MO US WASHING MACHINE CONNECTION MN�NMI! MIN�NM um nil No �_ ME NM MN NM IMO Nil WATER H WATER PIPING �-�� ®�� MIinn min um gig irgi g_i_i Eli N(NON 1111101111111.."MIN RINI al Ill Ell mu mill Am um um NM INN INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO 0 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 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 0 O SIGNATURE OF OWNER OR AGENT • I hereby certify that all of the details and information I have submitted or entered regarding this application ar-.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 c pliance with all Pertinent provision of the `n Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,. PLUMBER'S NAME'STEPHEN A.WINSLOW__ _ __ _ _1 LICENSE# 12298 SI ATURE c MPO JP® CORPORATIOND# 3281C PARTNERSHIP0#11111111111111 LLC - � COMPANY NAME'.EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE c- o TEL 508 394 7778 U- CITY`SOUTH YARMOUTH 'STATE MA ZIP 02664 --.9 - EMAIL accounts able,_efwinslow.com FAX 508-394-8256 CELLI N/A It (P (gig The Commonwealth of Massachusetts - • 1 1, Department of Industrial Accidents =_;;�;1= 1 Congress Street,Suite 100 it .�=8' Boston,MA 02114-2017 s� ' 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?Check the appropriate box: Type of project(required): I.0 I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction 2.6-lam-a-sale.propri4.tnr or partnership and have no employees working for me in _ $. n Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 0 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.Q 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 a paz s nd pen lties of perjury that the information provided above is true and correct Signature: I"' -°-� o� Date: Phone#:508-394-7778 V, 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#: