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Home My WebLink AboutBLDP-16-001407 t ,� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK T :, j _r CITY t 3 l! �r-�� (mei,Li-r--4 MA DATE qt ' ,1 PERMIT# r Dfr /(— 'W7 JOBSITE ADDRESS 4 R 7f1- yZ I OWNER'S NAME LiCt jr-LiLL „2 2 P OWNER ADDRESS d-t. e Y (7- l„).Q- TEc15-cls j 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ® RESIDENTIALg PRINT CLEARLY NEW:® RENOVATION:0 REPLACEMENT. PLANS SUBMITTED: YES 0 NOXI FIXTURES 7 FLOOR-, E BSM I 2 1 3 1 4 J 5 J 6 1 7 1 8 ` 9 J 10 J 11 J 12 J 13 j 14 BATHTUB re Nil! 'elfairy i CROSS CONNECTION DEVICE t lb / , DEDICATED SPECIAL WASTE SYSTEM tet, DEDICATED GAS/OIUSAND SYSTEM t DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER . AKI A 1 t `M RP 1 i'xpNAw jiti,_ DRINKING FOUNTAIN �� # N, FOOD DISPOSER ,.. ....._ ... FLOOR I AREA DRAIN , e_ ._ INTERCEPTOR(INTERIOR) KITCHEN SINK , , LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET w ar- .. .1 *Fir w URINAL vat ,s r r WAS ING.MACHINE.CONNECTION_ _ _ y WATE 2 HEATER ALL TYPES WATER PIPI . i,._._. OTH VT ' ' / r fit, e _y / ` INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES►,4 NO (l IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY'v41 OTHER TYPE OF INDEMNITY El BOND Q 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: 0 ER ® A SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are an rate the best my owledge and that all plumbing work and installations performed under the permit issued for this application will be in complian all ertinent pro 's of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4.-- PLUMBER'S NAME STEPHEN A WINSLOW J LICENSE# 12298 SIGNATURE NIFIR JP® CORPORATION#L3281C JPARTNERSHIP 0#L^41 LLCEj# COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA ZIP 102664 I TEL 508-394-7778 FAX 508-394-8256 I CELL 1 EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM 0 The Commonwealth of Massachusetts_ _ Department of I r c s?i?ll Accidents ^ ) =,vim_l Office of Investigations • 1 -',1'_ �y 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. 0 I am a general contractor and I 6 New construction employees(full andforpart-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- sub-contractors have ship and have no employees These8. 0 Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.❑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.❑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 poilcy 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 IA o insuranc, co erage veri c tion. I do hereby certify un a and enalties erjury that the information provided above is true and correct. 2016 Siertattrre: \ 1 _ 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#: