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Home My WebLink AboutBLDP-16-006719 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ::j CITY War, la I, MA DATE a/I. t,I /6 ERMIT# 0-4P-/6—016'7 q JOBSITE ADDRESS ,,,, ,;,fir OWNER'S NAME ,o//,I i,/,davargassmarsarmoy24L POWNER ADDRESS lir.` 1/ GAR,'"11 TEL FAX[_.........._.j TYPE OR OCCUPANCY TYPE COMMERCIAL OF EDUCATIONAL ® RESIDENTIAL av PRINT CLEARLY NEW:Q RENOVATION:® REPLACEMENT:®" PLANS SUBMITTED: YES® NO? � FIXTURES 1 FLOOR-, 8SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 , BATHTUB Mil NMI IIIII MIMI MEI MOM NMI MN IMMO NMI N Mil 1111111 I CROSS CONNECTION DEVICE amNUam lam MR NMI MOMNMIK Mal M"NMI OMR',OMB OMB . DEDICATED SPECIAL WASTE SYSTEM INK NM IMO MIK MOM OMR NMI NMI NMI MIMI MN OMR IMNI Int NMI "IS DEDICATED GAS/OIUSAND SYSTEM MIK on NM MK INK MIR MIK MI MIK NM a a a am am DEDICATED GREASE SYSTEM IMF N MIK NOM NM s M M NM an INN N`MIK NMI DEDICATED GRAY WATER SYSTEM air OM N M NM 11111 N M III NM IIMIIIIIIM M MIK.;MIK i DEDICATED WATER RECYCLE SYSTEM_ N am—1111.1._.0 11.1111 wit'n MOM — DISHWASHER MIK iili NE illNi 1111111111111111111111NMI MM.NMI—NMI'NE NMI DRINKING FOUNTAIN _Mill , _ , . ; r, FOOD DISPOSER ��_.: _ � ' .fi FLOOR/AREA DRAIN M MIK MINI MI S IIIII NS MI:MIMI NMI P I MI—all INTERCEPTOR INTERIOR .MS NMI MOM N,MIK!`;.Mat NMII:MIK I'MIMI KITCHEN SINK IIIIII MIN am MR MIK MIK MMN Milli NMI OMNI INK INNWIN ; MO MIK MMIN Iii min Nam o aim mum a.—.—°—NMI M ROOF DRAIN owa._INK MN IIIIII OM MINI.M IMO ONNMMMIN M• SHOWER STALLIIIIIIII IMO. �: i �; SERVICE/MOP SINK mmealii -_ �:� �_ -= TOILET � � ��! URINAL 1111111 MOM NM NMI INN MI IMO NIB MOM MIR MOM MMI NN.IIMII bk WASHING MACHINE CONNECTION iliii—_MMUM IIMII NMI NMI MIMI MIMI IMO, ;NIB WATER HEATER ALL TYPES sins IOW I INK NM IMMO MOM NMI OM MINI NE I MM.OM MIN IMEZIEMIIIIIIIIIIIIIIIIIIIIIIIII INK in*an ma III am inn MI NM MUM PIK NMI INF IMP MIK OTHER IIIIII OMMNM all IMO MIMI IIIMM NMI,IIIII MIMI OMR'MN—!Mililliiiil IMO am maw nor am ow au am saw am asi,aii Ian gam sat '. iiiiiiiiiiiiimallimill oat MI I M NU M INN MIR''Ua-OM VIM IIII.IIIII 01.11 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMIIIINII MIME MI III Ili Ina IOW MINIIIIII Nal IMO NMI NMI ow gm INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES LJ 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 Q 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 ® 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 complia ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A WINSLOW jLICENSE#[12298 SIGNA1E/ MP JP U CORPORATION j# 3281C PARTNERSHIP Q# v...__ LLC( # , COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA i ZIP 02664 1 TEL 508-394-7778 FAX 508-394-8256 CELL EMAIL ACCOUNTSPAYABLE.)EFWINSLOW.COM The Commonwealth of Massachusetts Y - - Departmant Industrial Accidents ► = ti Office of Investigations µ = ' 1 Congress Street, Suite 100 =11:!—,^7 Boston,MA 02114-2017 '��'a�7ti'' 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#:508-3947778 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 70 4. 0 I am a general contractor and I - employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.❑ Lam a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anycapacity. employees and have workers' P tY• 9. 0 Building addition [No workers' comp. insurance comp.insurance.* required.] 5. 0 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 employees. [No workers' 13.0 Other 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.. =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 that4.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. #: 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 fine 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 oft s IA or• uranc: co erage veridtion. I do hereby cert un, ,,4ins and,enalties erjury that the information provided above is true and correct. . Ap-- v Signature: Date: 2016 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. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: "'® 'Phone#: