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Home My WebLink AboutBLDP-16-000300_ ' K8ASSACHUSETTS00UFOR0 APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK JOBSITE ADDRESS M—C OWNER'S NAME[ Pvvwvcn*uuncoo /cL FAX TYPE OR OCCUPANCYTYPE -COMMERCIAL EDUCATIONAL RESIDENTIAL�� PRINT ' r�=/ CLEARLY NEW:�� RENOVATION: 0 N�| REPLACEMENT:Lf� PLANS SUBMITTED: YES[-INO[—'I FMURES"l FLOOR— oom 1 u 3 4 5 0 r 8 8 10 11 12 13 14 BATHTUB ��--�| CROSS CONNECTION DEVICE ___][--_�[__�[ � _- �__�[___��__' �---`�___�-___ OED|��DSPECL��S��EM �—T[_��_�[_��_�[__ —��- DEDICATED GASk}L�ANDSYSTEM r__�___7�__�[---� �__�[___ �__l[__]{ �--�[__�[__][_-_��__] DEDICATED GREASE SYSTEM r--- �--- __� F___�r_-__ __� DEDICATED GRAY WATER SYSTEM [_-- �---[--- r--� DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISR FLOOR ` LAVATORY nvvr - _ -- AI SHOWER uuacc_` SERVICE/ TOILET URINAL �—�F—� WASHING MAC INECONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER -` ^ -~--~�' =----�^^ ---- �---�'---r---�---��--�r-��-- r--��'--- ' �--� --'--- INSURANCE COVERAGE: � F� |b�u��m��m��m��m��L�1� `�[�. � � IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE ROL|0F] OTHER TYPE-OF INDEMNITY � BOND � OWNER'S INSURANCE WAIVER:|umaware that the licensee does not have the insurance coverage requiredby Chapter 142ofthe Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER �] AGENT E] SIGNATURE 8F OWNER ORAGENT hereby certily that allmmouma|manuinmnnaoon|xaveovbmiooxo,omemumuominnmisappxmmonomtmoandoccumtemmnuoot ofmvknowledge and that all plumbing work and installations performedunder the permit issued for this application will umi Massachusetts State Plumbing Code and Chapter 1*xm the General Laws. PLUMBEFYSN��E|STE H N ------- -->L|CENSE#[i22O8 SIGNATURE , M P� JP ��|�Q� ��E�H|PD �[� � `-, �� /-~'^/~ � '-^^��~.^~-~�� -/^�~~.~^~.--8 COMPANY NAME ADDRESS U ~~�_�-_ COY|SO STATE Z]Pknx: � TEL |—.~''' '~'`~~~''' FAX 256 CELLI. EMAIL . ~� 44). 01 0( �� ^ . ~� �� L "'^. \�] —. 0 , 7 ��'�� The Commonwealth of Massachusetts Department of Industrial Accidents mem;� 'I Office of Investigations 1 Congress Street, Suite 100 M��+�� i a �: Boston,MA 02114-2017 'fltrJr:Tv www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): E. F. WINSLOW PLUMBING & HEATING CO.,INC. Address:8 REARDON CRCLE 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 employer with 70 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. El Remodeling 2.El I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p tY 9. El Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t' c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *My 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. #: 1794 A Expiration Date:.01/01/2016 Job Site Address:CaC1hte S {f'+h City/State/Zip:O d / `moL.`'kl iti ,;�°�r �'',3 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised t t a copy of this statement may be forwarded to the Office of Investigations of tl t�e DIATnr insura a verage ve • cat n. I do hereby certi under pains a d penalties of rjury that the information provided above is true and correct. �' 2016 Si ature: Date: Phone#: 508-394-777 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#: