The URL can be used to link to this page

Home My WebLink AboutBLDP-15-001328 1: ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 't===rP CITY , /Qi�jY1L) Vil MA DATE PERMIT# &PP a0 )' z( JOBSITE ADDRESS / % OWNER'S NAME Jam/ S o/h P OWNER ADDRESS )1/�-1/ 11;/ lnd7/- 1 TEL / FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION:Q REPLACEMENT: PLANS SUBMITTED: YES Q N04 Q FIXTURES 1 FLOOR I BSM 1 l 2 3 I 4 5 6 I 7 8 1 9 l 10 11 12 13 14 IN BATHTUB r r r ri Z\ CROSS CONNECTION DEVICE t DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM V DEDICATED GREASE SYSTEMNor d r DEDICATED GRAY WATER SYSTEM f DEDICATED WATER RECYCLE SYSTEM DISHWASHER , , , r 4 O DRINKING FOUNTAIN , FOOD DISPOSER FLOOR/AREA DRAIN ism. INTERCEPTOR(INTERIOR) BEr; G KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK r TOILET URINAL WASHING MACHINE CONNECTION , WATER HEATER ALL TYPES I WA TL t PIPIN . ` , OT-IEFi raf4.;, `tiele , / • 1" „�,. ,ay .. - stye. �.v , /1 _' INSURANCE COVERAGE: I have a current lia.dity insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES L3 NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I j OTHER TYPE OF INDEMNITY Q BOND Li 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 Q AGENT Q 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 nd 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 comp' ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 6/i /J PLUMBER'S NAME I STEPHEN A WINSLOW i LICENSE# 12298 _1 SIGNATURE MPD JP CORPORATION#L3281C . j PARTNERSHIP El# I LLCQ#1 COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP I 02664 I TEL 508-394-7778 FAX 508-394-8256 I CELL- EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM YO P The Commonwealth of Massachusetts w-- Departt o Industrial Accidents - • ' ri _: Office of Investigations `'a►= 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#:508-3944778 Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with 70 4. ❑ I am a general contractor and I employees(full and/or pert-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' [No workers' comp. insurance comp. insurance. 9. El Building addition 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 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.0 Other 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. :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 andjob 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 t a copy of this statement may be forwarded to the Office of Investigations of tLBIA of r insuranc, co erage veri •tion. I do hereby certify un e s and enalties erjury that the information provided above is true and correct Signature: Date: 2016 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#: