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Home My WebLink AboutBLDP-16-000161 -H r • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK iii 4 CITYL(?MOC ;L::._ w MA DATE __ 7,_�._I.5 PERMIT#pi.dp-/X - 1/0 et. JOBSITE ADDRESS iv . OWNER'S NAME R� 't S1".r rc ," ... _ _ OWNER ADDRESS Gx„�y_lR i 1J I ierl 1 TELE(DfQ g7 - FAX L?� TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0, RESIDENTIAL Er PRINT CLEARLY NEW:D RENOVATION:IL1 REPLACEMENT: PLANS SUBMITTED: YES ri NOD FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB %' Il II II i_ I:1 CROSS CONNECTION DEVICE I !; `I,_ ' I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _T; _._ _- __...� , DEDICATED GRAY WATER SYSTEM "' r I, DEDICATED WATER RECYCLE SYSTEM ! DISHWASHER DRINKING FOUNTAIN - __...., ___ , �__ �___ ', • FOOD DISPOSER ;I .. • I 11 „; I 1 FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) '. KITCHEN SINK LAVATORY i ', ,1 i , ROOF DRAIN • — _._.. SHOWER STALL :; t: t•, )i 'i +; ._.. , II _ ; • SERVICE I MOP SINK '; I •I! . .... .1 :I— ,,- TOILET ! i ;I ,, x i • URINAL tI ._..._.4 I_—_,1� i ! AI_u_ ri _ I_ II _ I I. _ Adel AeR EL!- s 1 I V'AT / I CTH R •� , , I _� w _ + — �<J I ^l - ; T T 1-7 T. ..._:_' —, e.�.:; t I.�....:�_... ....e....-.._� .... -' .� f 1-.>._.._ .1_-... { I.j �W� F.J Lt — L 9 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ',-t NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY[J OTHER TYPE-OF INDEMNITY fl BOND 0OWNER'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 LT 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 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 co liance with all Pertinent provision f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME I STEPHEN A WINSLOW - LICENSE#112298 V SIGNATURE - MP II JP E i CORPORATION[j # 3281C _ [PARTNERSHIP _ j LLC[ # �- COMPANY NAME LE.F.WINSLOW PLUMBING&HEATING 1 ADDRESS 8 REARDON CIRCLE ' LI CITY SOUTH YARMOUTH 1STATE l MA ZIP [92664 ' TEL[508-394 7778 FAX 508 394-8256j CELL EMAIL [ACCOUNTSPAYABLE@EFWINSLOW COM ,.._..:,1 I5. — 3 (tZ: r CA).0. Ll()0?—' 7�(' 3 �ti- The Commonwealth of Massachusetts Department of Industrial Accidents - ._ #=;aL Office of Investigations taf 1 Congress Street, Suite 100 Boston,MA 02114-2017 • 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): 1.0 I am a employer with 70 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.t 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 11.0 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 41 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.#: 1794 A Expiration Date:01/01/2016 {/�� J r Job Site Address: c a f l !c as )p S City/State/Zip:LUp S r )Jci r WI)A .0 Gf 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 a copy of this statement may be forwarded to the Office of Investigations of t e DIA r insura a verage ve ' 'cat' n. I do hereby certft under pains a d penalties of duly that the information provided above is true and correct. 2016 Si ature: Date: Phone#: 508-394-777g 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#: