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Home My WebLink AboutBLDP-16-006641 y IZ . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK si 't j CIN �'C�C� •. __ MA DATE IAA t( - .J PERMIT#lee--#— PERMIT 9/ JOBSITE ADDRESSN. ..1-1,2` OWNER'S NAME p ,,, - POWNER ADDRESS FAX TYPE OR OCCUPANCY TYPE PC60t1 IIERCIAL lcs— EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:14' PLANS SUBMITTED: YES❑ NO .12 FIXTURES Z FLOOR-+ BSM ( 1 2 3 J 4 5 6 7 J 8 1 9 10 I 11 12 13 14 BATHTUB j 4 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM i NM DEDICATED GRAY WATER SYSTEM 011.11111411.110111111 01.01 INS DEDICATED WATER RECYCLE SYSTEM aiNiiiialIMMIlaininalleaRIPOIMINIMINI INK DISHWASHER DRINKING FOUNTAIN.. '. FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY 1111111111111.1111111411111.111111 11111111M IIIIIIIHNIIK MI ROOF DRAIN SHOWER STALL , e :�: .,::V ' 1 y,. ' x SERVICE/MOP SINK r TOILET URINAL WASHING MACHINE CONNECTION MI illinlillailliMill. NM WATER HEATER ALL TYPES = WATER PIPING iiiii OTHER 40 ,_ 1111.1111111111111.1111111111.11111111""""""1"111 111101 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 LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND ❑ OWNER'S INSURANCE WAIVER:I am are 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 ❑ 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 t e 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 co lance with all Perti nt p sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. // PLUMBER'S NAME STEPHEN A WINSLOW � LICENSE#112298 �1 SIGNATURE MP JP CORPORATION#i3281C-., PARTNERSHIPQ# _I LLCD#L_ COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE( MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 I CELL_ EMAIL ACCOUNTSPAYABLE. EFWINSLOW.COM t): )A.4( 9 (�� a.P The Commonwealth of Massachusetts , Department of In asriial Accidents )-=10,,,...........E'� Office of Investigations __'i!+; 5 1 Congress Street, Suite 100 +. •,:f:r= V ! �, _.,_ Boston, MA 02114-2017 '>:r. www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly •Name (Business/Organization/Individual): E. F. WINSLOW PLUMBING & HEATING CO.,INC. Address:8 REARDON CRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone#:509'394-7779 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 70 4. ❑ I am a general contractor and I 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors 2--❑-;:arae-stile propt=ietar-or-partner— —__ - listoiontheattached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152,§1(4),and we have no 13.❑Other employees. [No workers' comp. insurance required.] *My 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 andjob site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins. Lic. #:1794 A Expiration Date:01/01/2016 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 fme of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of r 'IA o • uranc, co erage verition. I do hereby certify tun' • e ' s and,enalties ,rerjury that the information provided above is true and correct: 2016 Si at • �� A- Da • Phone#: 508-394-777 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.CityfTown Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: phone#: