HomeMy WebLinkAboutBLDP-22-006941 ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
"" CITY YARMOUTH(WEST) MA DATE 5/26/22 PERMIT# -'I
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JOBSITE ADDRESS 18 VACATION LN,W YARMOUTH,MA 026731 OWNER'S NAME ED&DORRINDA SHEA
P OWNER ADDRESS SAME I TEL (508)728-6145 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:Ej RENOVATION:0 REPLACEMENT:ED PLANS SUBMITTED: YES ED NO
FIXTURES 1 ••' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE i I
DEDICATED SPECIAL WASTE SYSTEM 1111. i.1111
DEDICATED GAS/OIUSAND SYSTEM j'
DEDICATED GREASE SYSTEM 1111111111111111111111111111111 1111111111111111111111E11111111111111111111i EMI IMF 1.11.111111
DEDICATED GRAY WATER SYSTEM M. ,I
DEDICATED WATER RECYCLE SYSTEM _ 1 _ _ immunising"
DISHWASHER Mill al iiitilial rMiIallitill. i
DRINKING FOUNTAINM.
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• DISPOSER 1111111111WW111111111 ` , l
FLOOR/AREA DRAIN . G
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1 1WATER HEATER ALL TYPES I LAVATORY -Run nun ,_... L..,., ,n
ROOF DRAIN I
SHOWER STALL
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SERVICE/MOP SINK
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WATER PIPING
OTHER ICE MAKER 1
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SILLCOCKS 2 .,
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES pi NO
ED
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITY ED BOND Ej
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 Ej AGENT Ej
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 r e to the b t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co Ii wit II ertine proyisio of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN WINSLOW r G '"`A`"''�
,LICENSE# 12298 SIGNATURE
MP El JP® CORPORATION Li# 3281C PARTNERSHIP #L „_ LLC Q#L
COMPANY NAME I E.F.WINSLOW PLUMBING&HEATING I ADDRESS 1,8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE I MA ZIP 102664 TEL 508-394-7778
FAX 1508-394-8256 I CELL I N/A EMAIL INSPECTIONS@EFWINSLOW.COM
The Commonwealth of Massachusetts —
Department of Industrial Accidents
!z j
�' f Office of Investigations
_" = Lafayette City Center
• �"? 2 Avenue de Lafayette,Boston,MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 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: Business Type(required):
1.❑� I am a employer with 99 employees (full and/ 5. ❑Retail
or part-time).* 6. L J RestaurantfBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no
7. ❑ Office and/or Sales(incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]**
4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. #1964A Expiration Date:01/01/2023
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under § 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 of
the DIA for insurance coverage verification.
I do hereby ce ' of the ins and penalties of perjury that the information provided above is true and correct.
Signature: 7�I-- —4/ 12/01/2021
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(check one):
10Board of Health 2.0 Building Department 3D City/Town Clerk 4.El Licensing Board
5.0 Selectmen's Office 6.['Other
Contact Person: Phone#:
www.mass.gov/dia