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HomeMy WebLinkAboutBLDP-16-002762 1, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t I -1' CITY (4� /,Urn frill Ti- . t (�._. - MA DATE 1 I1[,5- PERMIT# 19f to O s 0 7( JOBSITE ADDRESS a no I OWNER'S NAME et A -Q - . Q-cc POWNER ADDRESS L ( `_ cs Lo<1SZ TEL ni- 4-ik31.4 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALIZI PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:a PLANS SUBMITTED: YES❑ NOJ FIXTURES 1 FLOOR-, I BSM 1 1 2 1 3 1 4 5 1 6 , 7 1 8 1 9 10 1 11 I 12 I 13 J 14 BATHTUB 1 . CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM d DEDICATED GAS/OIUSAND SYSTEM ,�. ' r DEDICATED GREASE SYSTEM a , I DEDICATED GRAY WATER SYSTEM I _DEDICATED WATER RECYCLE SYSTEM 30 DISHWASHER 1. N. DRINKING FOUNTAIN '1 k l t, ,.. -lkf MO. II III.. A. . FOOD DISPOSER ..., FLOOR/AREA DRAIN EMI .. INTERCEPTOR(INTERIOR) �... _ KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET _ „ey ( URINAL WASHING MACHINE CONNECTION r ;i,, lot r, WATER HEATER ALL TYPES WATER PIPING ° * . .. ,„ ". OTHER .. . iliMilli �.. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES J NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY* 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 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 com 'iance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' � / „' . PLUMBER'S NAME STEPHEN A WINSLOW J LICENSE# 12298 r SIGNATURE MP(I JP{:3 CORPORATION #[3281C , ,PARTNERSHIP❑# LLC❑# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING J ADDRESS 8 REARDON CIRCLE I CITY SOUTH YARMOUTH STATE rMA , ZIP 02664 3 TEL 508-394-7778 FAX 508-394-8256 1 CELL 1 EMAIL ACCOUNTSPAYABLE©EFWINSLOW.COM 1 L 1h-21 I 1 V1/4---, -.- ii a The Commonwealth of Massachusetts Department of If u'tts?l al Accidents l Office of Investigations y 1 Congress Street, Suite 100 Boston, MA 02114-2017 r; ' 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 #:508-3944778 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 70 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2:El fain a sole proprietor or partner- - - listed on the-attached sheet. 7.-0 Remodeling These sub-contractors have 8. Demolition ship and have no employees ❑ working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.t required.] 5. 0 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 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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. #: 1794 A Expiration Date:01/01/2016 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 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 that a copy of this statement may be forwarded to the Office of Investigations of s o ' uranc: co erage veriJtion. I do hereby certify un erins and 'enables p erjury that the information provided above is true and correct. — � 2016 is ais: Dat-: 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#: