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HomeMy WebLinkAboutBLDP-20-000665 MASSACHUSETTS UNIFORM APPLIC� I I ®R A PER MI'P"'T�PERFIR PLUMIi316�GiNORK "= CITY 4iimov ft.. - __.i MA DATE - - J1L' PERMIT# ,ice Y JOBSITE ADDRESS 1iOC4p-I- ; arino L. OWNER'S NAME ON '1AI 01664 P O TEL SOS39N431 a FAX 11111111111111111 8 E s 3RESS I� CVt'►'Ihe(l�n�l P cf LtomiLlr M A TYPE OR OCCUPANCY TYPECOMMERCIAL© EDUCATIONAL ® RESIDENTIAL la"— PRINT NOD CLEARLY NEW:El RENOVATION:® REPLACEMENT:®� PLANS SUBMITTED: YES FIXTURES Z FLOOR--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB .MI 11111 MM.iii.MN CROSS CONNECTION DEVICE NI - _ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM _- tp, la DEDICATED GREASE SYSTEM -_ MN_ an DEDICATED GRAY WATER SYSTEM MI __ illAi IMP � DEDICATED WATER RECYCLE SYSTEM WIN _ - -- - DISHWASHER IIIIIIEMP - - _ I ,� DRINKING FOUNTAIN _ - - _ liii FOOD DISPOSER _ R _. NO NM NO NM F I AREP,DRAIN -_. -- -INTERCEPTOR - (INTERIOR) KITCHEN SINK LAVATORY - -- --�. -- _ ROOF DRAIN 1 MN SHOWER STALL - SERVICE I MOP SINKMN am TOILET URINAL WASHING MACHINE CONNECTION _ WATER HEATER ALL TYPES _ WATER PIPING -- OTHER -_- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES O NO Ej IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND El 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 0 AGENT SIGNATURE OF OWNER OR AGENT hereby that all pmbinglwork and installations performed under the submitted pe m t issued entered regarding this applicationplication will be in re tru nd accurate to the best of comp! knowledge of the details and information I have or compl nce with all Pertinent prov s on of the and Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEI STEPHEN A.WINSLOW__ 'LICENSE# 12298 SIGNATURE MPO JPD CORPORATIOND#(3281C 'PARTNERSHIP®#I 1LLC I COMPANY NAMEI EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE Ir S o CITY'SOUTH YARMOUTH 'STATE MA ZIP 1.2at6.L._.____1 TEL 508-394-7778 FAX'508-394-8256 1 CELLI N/A (EMAIL I accounts a,able aefwinslow com UO 7 • The Commonwealth of Massachusetts • 1, Department of Industrial Accidents "_;;jell= 1 Congress Street,Suite 100 • <k Boston,MA 02114-2017 . www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):E.F. WINSLOW PLUMBING &HEATING CO., INC Address:8 REARDON CIRCLE 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 88 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership-and have no employees-working for me in - 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.1=1Roof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no 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 and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic.#:1909A Expiration Date:01/01/2020 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and a pai s nd pen Ides of perjury that the information provided above is true and correct Signature: Date: Phone#:508-394-7778 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): N 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: