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Home My WebLink AboutBLDP-20-001485 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ = MA DATE • Z q PERMIT Q-tf(J l �If e li` '�_ CITY` YnlmOUfH -, f1- ■ JOBSITE ADDRESS 1 2 1 &eed1R✓► gr) 7f,norJ O✓,Z I OWNER'S NAME - - P OWNER ADDRESS I31 CIycSdale Or P1 -t-c- eh1MA 01201 1 TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL PRINT PLANS SUBMITTED: YES® N0� CLEARLY NEW:ElRENOVATION:❑ REPLACEMENT:Er-- 5 6 7 8 9 19 11 42 sm� BATHTUB FIXTURES 7 FLOOR + Bid In NM ONIIIIIIIIIIIIM 3 4 O INN NM NM — NM N BATHTUB - �� CROSS CONNECTION DEVICE illli MN 1.1111.1111111._ ION . MI DEDICATED SPECIAL WASTE SYSTEM IN MN um a DEDICATED GAS/OIL/SAND SYSTEM MIMI NM NEIN 1.1181.1101111 DEDICATED GREASE SYSTEM -- MN N l MIN MIK DEDICATED'GRAY WATER SYSTEM NEImii,— ----- X X DEDICATED WATER RECYCLE SYSTEM NMI INN i•IIIMIIIIIIIIIIM DISHWASHER - _ —_ m i. DRINKING FOUNTAIN ill NM Mil MIIIIIIIIII.11 I�i I ' FOODDISPOSER M MIIMMI �� MI WO NM INN FLOORIAREP.DRoIP! �� - - INTERCEPTOR(INTERIOR) in tin NMI 1111.11111111111M IIIIIIIIIIII NM IIIIIIIIIII INN MN MN MN KITCHEN SINK MN N NM I>11 LAVATORY 1 -- = � NM MI��NM ROOF DRAW - -- I I - SHOWER STALL Wig MNNMON SERVICE 1 MOP SINK NEI NMI MI - _ TOILETililiEn 1.1.111111111.11 NMI illill Um �MNNMNM on um 10-110g URINAL WASHING MACHINE CONNECTION 1!4 MI iilI NM NMI MI WATER HEATER ALL TYPES NMI MI NMI IIINIMIIIIIIIIIIM 1011111111.1 MN NMI MIN ININ NM NM NMI WATER PIPING MN NM MR 111001 MIMI IIIIIII NON MN MA NMI MN NM �! OTHER - PM IIIIIIIIIIIIIIIIIMMON111.1111111 NMI ME MI IIIIMINIMIll 111.111.111 MI WM MI MI MI NM NM MI WM ME MOM MI MUM NM MI ME AM - MOM MIN MOM 1111111110111111111.11 111111111011111 E111101 NM MN INN MI NMI= - - - 'NMa®MI MIN MN INSURANCE COVERAGE: l have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESO NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY❑ BOND 0 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 I hereby certify that all of the details and information I have submitted or entered regarding this application are tr 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 co ' nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � � a ' STEPHEN A.WINSLOW _LICENSE# 12298 +'�" 1 IS GNATUR 'ems PLUMBER'S NAME MPQ JP❑ CORPORATIOND#I3281C (PARTNERSHIP❑#I 1 LLC❑#111111111.11 cz' a' — COMPANY NAME EF WINSLOW PLUMBING&HEATING I ADDRESS I 8 REARDON CIRCLE 394 7778 - 4 CITY SOUTH YARMOUTH ,STATE MA_ ZIP 102664 TEL -_.—"-' Q v' FAX 1508-394-8256 1 CELL NIA EMAIL I accounts a�able(�efwinslow com - - I; The Commonwealth of Massachusetts I —=, 1� 1, Department of Industrial Accidents ki =�1' 1 Congress Street,Suite 100 � if 4, Boston,MA 02114-2017 5,, .1 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 sale-proprietor or pa, and have no employees working for-rne in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demolition 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 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:hoof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have e 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 epai fs ndpen lties of perjury that the information provided above is true and correct. o 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 one):: �N 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: