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Home My WebLink AboutBLDP-20-001043 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUM=ING WORK 14►4 Ka) "-?ire PERMIT#/:r^�l -c'�O A��4' j j CITY I Yu/filow 114 MA DATE WORM JOBSITE ADDRESS 180 6 reeniku►J Cite t jlq/41_,tg+Ach1-I OWNER'S NAME Robe t 0 NERAD�RESSI <Ctd.Yle I TEL M II fr FAX PRESIDENTIAL®' TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 PRINT PLANS SUBMITTED: YES® NODCLEARLY NEW:® RENOVATION:® REPLACEMENT:�� FIXTURES Z FLOOR -4 BSM 1 2 3 4 5 6 7 8 9 19 - -11 12 ENE BATHTUB NM MN M NMI linM M_ION M MN MN PM CROSS CONNECTION DEVICE OM NM Il N MN OM OM IN OM M OM II NM MI II DEDICATED SPECIAL WASTE SYSTEM N IN sil u um nig NO MN ON IIONIO' OM MONE MI MIR DEDICATED GASIOIUSAND SYSTEM IIIII NI LEI NM mg in um ppm mg mai imoNM um IIIII MI DEDICATED GREASE SYSTEMIIIII •••am um um um um um am ow um in WATER RECYCLE SYSTEM NM NMMO OM WIN NMI OR MEI OM MIMI MN WI I� DEDICATED NM MI I��'� I! MO NM MI MP DEDICATED GRAY WATER SYSTEM MI MR�� --- -DISHWASHER----- --- --- - - ---�� _ DRINKING FOUNTAIN N_OM MN Imo' III I MN NM PM OerMI 1111111101 OM NM III I� FOOD DISPOSER I_ MUM I NM OMR OM FLOOR IAREADRAIN NM OM W-am I= - I li O1111111 NMI _ _ IM INTERCEPTOR(INTERIOR) M MIMINMNOMM� _ 111111111111 KITCHEN SINK MI len MI Mil INN MI OM Mil NM MI MI MI NM_ MI Mil LAVATORY MIN Ilia im mill MR MN 1111111.111 MX WPM MN MI MUM ROOF DRAIN _I NMI 11111111 MI OM OM MN NMI MI OMINN MR AMID SHOWER STALL illli NM iii MA N N 11.11111 all MI WM PM illik IN lin MI MI SERVICE MOP SINK MN IM NMI Ili M a`NM MN IIIII NM UM-NM TOILET11•11MIN �MOMIIINII INA URINAL II -WASHING MACHINE CONNECTION III Il a PM IM1 MN M OM Pal MI nip um 11111111111111 NM WATEOM IIIMI OM NM MI_ RPPNGRALLTYPES MMOI I IMI NM II In' MIMR NM PEP Iffil um pm pm Igo an nitWAT R NM t - n NM II - OTHER -_�" i G2_ htl ' r �� I� � � �I�':. 111111111.1.1111_11.111MI WWI Mil MI In WM MN MI NM MN NMI NM MI MI NM lila IN MN ME MIMI IMO MN MI Mill MI MI all MINI NM UM NMI Mil _ME IMO MOM nil ION NMI NM WIN 1111.11111.1111111 lin MN OMR INN INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E] NO 0 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:l 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 and accurate to the best of my knowledge 0 and that all plumbing work and installations performed under the permit issued for this application will be in co lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I STEPHEN A.WINSLOW _ _ "LICENSE#112298 I SIGNATURE C.-4 CORPORATIOND#I3281C IPARTNERSHIP�I# -LLC c'' S MP❑ JP® !'. `r COMPANY NAMEI EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE ----- - -- s � � CITY'SOUTH YARMOUTH 'STATE MA ZIP 1.0221........______I TEL 508-394-7778 FAX 1508-394-8256 I CELLI NIA I EMAIL I accounts payable efwinslow com IA_ � `-' ( -' J The Commonwealth of Massachusetts =, �=_ .l, Department of Industrial Accidents __�,1 1 Congress Street,Suite 100 �_, �-„` Boston,MA 02114-2017 5�, www mass.gov/dia U.4 Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH MI,PERMITTING AUTHORITY. Applicant Information Please Print Legibly A Name(Business/Organization/Individual):E.F. WINSLOW PLUMBING & HEATING CO., INC V \ Address:8 REARDON CIRCLE N\ ( `p . 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 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. 0 Remodeling hl' any rapacity [No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑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.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13•111 ROOF 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.❑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 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.Lie.#: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 irnprisonment,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. N I do hereby certify and a pars nd pen lties of perjury that the information provided above is true and correct l Signature: Date: P _ , ' t-, Phone#:508-394-7778 � 0 3 Official use only. Do not write in this area,to be completed by city or town official n 1 City or Town: Permit/License# k 4 Issuing Authority(circle one): d 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Ins for . 6.Other Contact Person: Phone#: _ i (1 b