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HomeMy WebLinkAboutBLDP-20-002420 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK —'iti= 10/24/2019 B .17.1 CITY/TOWN YARMOUTH MA DATE PERMIT#/ -il� ° —COPrigo `= 77/ JOBSITE ADDRESS OWNER'S NAME 20 DRIVING TEE CIRCLE CONWAY OWNER ADDRESS SOUTH YARMOUTH TEL 508.398.2845 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES❑ NO IY FIXTURES Z FLOOR—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES I5 ' NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY g OTHER TYPE OF INDEMNITY ❑ 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 t'r- 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;�'•liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE - MP[i JP❑ CORPORATION[a# 3281C PARTNERSHIP❑# LLC❑# COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspavable ai7.efwinslow.com WORK ORDER 514623$50.00 - t if t F The Commonwealth-of Massachusetts a, ,�t. Department of Industt7atAecidlents c t 1 Congress S'tree4 Sufte 1•0 P� ,y Boston, 02114-2017 . N-' www m ass•gov/dia Workers'••Comipensation Insurance davit;Bbalders/Contractors/Elects cians%P,luaibers.. TO":lam'011,tit WITH THEE-nith41TrIN0 AVTHORI TY_ Appleant�liitifroiation: .Please Paint: biY= Nee( usitiord 3rgaigt b ulindiv+idriati.E.f•WINSLOW PLUMBING--—,HEATING ©„.:INC: Address;8 F EARD N CIRGLE City/Stater ii SCIUTH YA►RM.QUTH.x MA.02664 Rholxe#:5084394'✓'7778 Aae.Yua.an ployar'Che the aPi+ p.. bo:: Wimp!project(required): 1, dam aciiipiidyerv�lith 88 employees(fulhind/or part-time)•• 7 " ❑,Nettit eenstetiot3 - ro mr Y a1 8. Remodeling; 2,04'ankasole prgoetoror punnet Mi ,sndhave no a kr eesvorkin form n any capacity.-(No-wow?comp intuiance required.) Q • d.0I dun a'hoineowner.doingatl work.myself.',[No workers'comp,' required j? 9 Demolition instuarrc_ 4�j.amahOmites nerand wall ba.'iurin contractors to conduct au work on'm 10 O"Btxilding scldttitln• S Y property.. I vrill Wino thataf eonttaaaore eItlierhave workers'compensation mauronesorare sole 11 D-E1 oal r ae*TS�Orxa tibia$ pmprietota>wtth•n+i.anpioyees. 12,ii Plumbing reptu :or.-addd ons 5.0 lamagei ore coptractorand I bawc�lured=the su• bcontrautort1isted on**attached Sheet 13.pft�f:�. Thmsasub oontrestote}iavextlmpioyersand have- orkcts'comp.indutpriee t searea- 14.Dotber. El' aaoti ati t ofr,..chays ptercised.theu sight orea2em a per`moi-o; 15241(4)andwehavenosemployees.(Noworkers'-comp.tnsuranctlrequired) oMyajr'{t ilitlfh�h�G r must alsoliiltout�ttie on below showing�their wodt�'compensation-pnliey idtam atlpn." - t nomedwsteacvtsorspbn tt t>� 'itiavit�irfdicatutg they are doing atl<work attd thanhire outside centraofors rliust submrtstaewaffidavit`mdiO5thtg aucli. hCont}ootorot#t� t '`of must attached an additional shterahowing'the name.ofthe ub-contractors•an"d state wltet`liet of not those have i itilgi yt s tlactor- a layeesx the)!.must j3rovicte worker 'cootnp galierrluull ei. J, I tC n-aneniployer�tkat°is providingIworkers'compensation Insurance for a loyees Below is the polley antjob site in o:M ntfon. Insurafict com$ny'Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self ins.tic.#:19°9A Facpiration Data 1i01/2ti20 Job Site./4ddress. .. .Cif!/8tateiG :,,_ .. - . ,r Attach a copy of tht:Wetkers'compensation"policy declaration page(gbowing•the policy number anti cxpii rattiti'tio date}. • Faihire•to secure coverageas required under MGL c. L37r,§25A is a criminal violation punishable by"a&watt-,io 1,500000 and/or one-year imprisonment,=as well as civil penalties in the form of a STOP WORK ORDEWarnd.a fineafup to$250 00,a day-against°the•vtolator.A dopy of this statement may forwarded:to the Officer-of Investigations.of the DIA for utsurance coverage en' , atiosn X do hereby cend u $-. tip `•Net ofpe iury tliaite tision ration.proVl e4 abm►e is.tr e t correct S ..„—.. _ Date. Phone 0s'9a"777s \a Nt ©,fj`!`cYalisse orilt. Do not wii .iri=t/ets area,to be completed by city-or'townoJ1iciab: City or'Town:: Permit/License# issuing Authoflty=(clrcle One): . A:- 1.Beard.'of Uealth Z Buil+dtng Dt partr ent 3..City/Towit Clerk 4.Electrical inspet the S riownbing;Frifipector .. CtfnmdfPerson:: Phone#: