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Home My WebLink AboutBLDP-20-000877 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK W_"_ CITY Vg ii na 6414 _ 1 MA DATE DATE14 =1 PERMIT#el n4_P:-OD°g7r JOBSITE ADDRESS Ig8 Ansentlikk IA, w.Y4! OWNER'S NAME 0 . i - A' i __ _',i- -- -A• - ` O C Bator P OWNER ADDRESS I SAtr4 -1 TEL`OD4'53 q(,o k D 1FAX IIIIIIIIIIIII TYPE OR OCCUPANCY TYPE COMMERCIAL[r EDUCATIONAL El RESIDENTIAL PRINT PLANS SUBMITTED: YES ] NODCLEARLY NEW:® RENOVATION:El REPLACEMENT: FIXTURES 1 FLOOR-* BSM 1 2 3 4 5 6 7 8 9 L 14 11 12 13 14 BATHTUB _ iliN NMI MI CROSS CONNECTION DEVICE MI IMPINNIIIM illitIMILIIII OMNVON MIMS MI NM OM MI DEDICATED SPECIAL WASTE SYSTEM IIIIIII NNNIIIIIIIIIIIIIII MN 011111111111001111111 OM Mil MI DEDICATED GASIOILISAND SYSTEM _ RIM 11111111111.111.1111 MI DEDfCATED GREASE SYSTEM MI_ - PPpli RP DEDICATEDGRAYWATERSYSTEM _— ___ -__ I DEDICATED WATER RECYCLE SYSTEM MI t4zi DISHWASHER - --- - _- 7 - am DRINKING iliii - - O FOOD DISPOSER / - � ._ _ � - � MI FLOOR I AREA DRAIN _ ini MAIM NM ail INTERCEPTR _-�---•�� r KITCHEN SINK(INTERIOR) NM -- LAVATORY UPI - _- - , MP to() ROOF DRAW or SHOWER STALL MIN= V) SERVICE 1 MOP SINK TOILET �.. 9 Mal MI 1.1.11111.1.1111011.11.1111 0 URINAL e WASHING MACHINE CONNECTION WATER HEATER ALL TYPESCkC _ WATER PIPING —-- Imo ....� OTHER V L)C 245 EL:v 1(i __ tanJsu'r S on _ ._.. ‘.3.- INSURANCE COVERAGE: ( "• I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[ NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 'Z--. LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND ^^ t-�-- 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 0 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 and 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 c pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1ith/ PLUMBER'S NAME I STEPHEN A.WINSLOW LICENSE#112298 SIGNATURE MPQ JPD CORPORATIOND#I3281C 1PARTNERSHIPID 11111.111111111 LLCIDIL I COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 18 REARDON CIRCLE 1 CITY SOUTH YARMOUTH - STATE MA ZIP 102664 TEL 1508-394-7778 FAX 508-394-8256 CELL N/A EMAIL I accountspayable@efwinslow.com _ —44111- 1 D lig 3 ...- 's.,........ . . The Commonwealth of Massachusetts \ Jo' I Department of Industrial Accidents Cv h _ 1 Congress Street,Suite 100 Boston,MA 02114-2017 - d www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. N TO BE FILED WITH THE PERMITTING AUTHORITY. t) Applicant Information Please Print Legibly t\ E.F. WINSLOW PLUMBING& HEATING CO., INC Name (Business/Organization/Individual): cccr- 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 v LEI I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction 1:0 I am a sole propi�etor or partnership arid have no employees working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 9. 0 Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t \ ❑ 10 El Building addition '''''''''....\ ,... 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 44- ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.EI Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.0Roof repairs Lci 'vk.. , 6.1=I We are a corporation and its officers have exercised their right of exemption per MGL c. 14.ID 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 infprrnation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must subthit 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 V \V\ information. . . . Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY \,-> Policy#or Self-ins.Lic.#:1909A Expiration Date:01/01/2020 t 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 lties of perjury that the information provided above is true and correct. Signature: �° "s• �� 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: