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Home My WebLink AboutBLD-20-003227 • lax MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '" I - CITY L�� MA DATE. ....)��.7,m L9Ij PERMIT#iii_/) -40-06 ',"'<-2 j JOBSITE ADDRESS -f 4 `. . . if l,% OWNER'S NAMEa iZgA_N4-''/L-CI 1 Pt OWNER ADDRESS ...S f TELT SO/73 7 7a5'FAX L TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL 0 RESIDENTIAL rqq PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO0 FIXTURES Z FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB IIMIKNIMS; M'MNM IIIIIII AM Ui CROSS CONNECTION DEVICE f ,. �'. �� F . DEDICATED SPECIAL WASTE SYSTEM Wow _OM a:mg micami f gm f DEDICATED GAS/OIUSAND SYSTEM , DEDICATED GREASE SYSTEM Mt� �,ant� 1111114111.111 11111111111111�.SIM NM RIR NM MIN NM DEDICATED GRAY WATER SYSTEM � _ - - UM_M"=- OS Mk DEDICATED WATER RECYCLE SYSTEM DISHWASHER --. �r � i1i�� DRINKING FOUNTAIN _. IMMI XIII� FOOD DISPOSER �allialarall �''M_ - FLOOR/AREA DRAIN i 1 �i�i, INTERCEPTOR INTERIOR � KITCHEN SINK �s_� �Se E LAVATORY � _ ROOF DRAIN : E SHOWER STALL �- 1.:. WIPP - WINVIEVAIIIIIIII SP_. �( SERVICE/MOP SINK - TOILETAllaantill. i �' URINAL + ."�, a.,, ! ON tl WASHING MACHINE CONNECTION �� WATER HEATER ALL TYPES 'r '11111111111111111111.111.1111111.111111.1 Mem, WATER PIPING um ii.MIMI lapialiamintaimillintaiillinrim ' OTHER , _ _-, m _ PIMIll IIIIIIIIIMI_. _.. SITNINIONIUMINWMISMIT '._ INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO D. IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY El OTHER TYPE OF INDEMNITY Q BOND E] 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 I hereby certify that all of the details and information I have submitted or entered regarding this application are ue 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 pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME[STEPHEN A.WINSLOW ' NA U�`-4. ... . ..��.::. _:._.mM. LICENSE# 12298 xM SIGNATURE MP}j JP CORPORATION 3281C 'PARTNERSHIPL I#1 I LLC F#r __1 COMPANY NAME I E F WINSLOW PLUMBING&HEATING ADDRESS L8 REARDON CIRCLE cirri SOUTH YARMOUTH ! STATE MA ZIP 02664 : TEL 508- __. 394-7778 FAX I 508-394-8256 !CELL j N/A EMAIL ACCOUNTSPAYABLE EFWINSLOW.COM lit) a L/2/I" 0 • The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 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): p i.0✓ I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction _ _ _ 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doingall work myself. t 9. El Demolition y [No workers'comp.insurance required.] 4.01 am a homeowner and will be hiringcontractors to conduct all work on my10 Building❑ addition ❑ 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.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof 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. 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 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 par Ind pen Ines of perjury that the information provided above is true and correct. 0 Signature: -� ,y Date: Phone#:508-384-7778 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#: