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HomeMy WebLinkAboutBLDP-23-003283 The Commonwealth of Massachusetts '! r. Department of Industrial Accidents `Is COMM Office of Investigations n._ ' Lafayette City Center C t 2 Avenue de Lafayette,Boston,MA 02111-1750 err„,'. 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.El I am a employer with 99 employees (full and/ 5. 0 Retail or-part-time),* 6. 0-Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. 0 Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 4.0 We are a non-profit organization, staffed by volunteers, 11.0 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. #1964AExpiration 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 cer • the ins and penalties of perjury that the information provided above is true and correct. Signature: -+ ......1.---- Date: 12/01/2021 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 3.0 City/Town Clerk 4.OLicensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#• www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - -et CITY YARMOUTH MA DATE 12/13/22 PERMIT# BLDP-23-003283 450 STATION AVE �� JOBSITE ADDRESS� OWNER'S NAME IBOTSINI-STATION LLC P OWNER ADDRESS 450 STATION AVE SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES El NO❑ FIXTURES z FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 2 WATER PIPING OTHER OTHER DESCRIPTION: 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❑ BOND❑ 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 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 'Stephen Winslow I LICENSE'12298 1 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# ' I LLC ❑# I COMPANY NAME (STEPHEN A WINSLOW I ADDRESS 18 REARDON CIR 8 REARDON CIR CITY IS YARMOUTH I STATE IMA I ZIP 102664 I TEL 15083947778 FAX ( ' i CELL I EMAIL linspections@efwinslow.com �i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �'°FI® CITY YA„RMOUTH MA DATE 12/8/22 PERMIT# Z 3— 'z 3 JOBSITE ADDRESS 450 STATION AVENUE 1 OWNER'S NAMELBOTSINI STATION LLC OWNER ADDRESS SAME TELL 508-367-7200 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ID EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:0 RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES® NO FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I ' _ „,_ CROSS CONNECTION DEVICEii ( DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM 1� 'I �1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 1 lair IPTINVINIMEIRMI l DISHWASHER DRINKING FOUNTAIN 1[ a:�, �r _III � 1 FOOD DISPOSER FLOOR/AREA DRAIN 1 of �� `i �� .. INTERCEPTOR(INTERIOR) KITCHEN SINK € �Q -< I AI . t Of uIlik � .- , R_... _i, ,ng1 � t �r LAVATORY j ' .. r .� _ _._. ROOF DRAIN - Al- , SHOWER STALL Ili 1 �IIIIFIIIII , IIIMFIIIWIIINFIIIIIF SERVICE/MOP SINK jl TOILET MN NMI t j ' _ I__ M MI 1.1111111111 MIN MS an INN URINAL WASHING MACHINE CONNECTION MRINIMPIIIAIWWWWW/111111 `NNW , i na' I WATER HEATER ALL TYPES WATER PIPING at an 1 I, , OTHER ii I :m a it m _111.11111...m......111111111111l' Ji I INSURANCE COVERAGE: E I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES(l NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Eli OTHER TYPE OF INDEMNITY ® BOND 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 AGENT ii I hereby certify that all of the details and information I have submitted or entered regarding this application are true a 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. PLUMBERS NAME[STEPHEN WINSLOW _LICENSE# 12298 G. � '. ._ � SIGNATURE MPO JP0 CORPORATION El JPARTNERSHIPO#1 1 LLC0#I COMPANY NAME E.F.WINSLOW PLUMBING&HEATING J ADDRESS 8 REARDON CIRCLE CITY I SOUTH YARMOUTH STATE L MA I ZIP 02664 1 TEL 508-394-7778 FAX 508-394-8256 I CELL I N/A 1 EMAIL INSPECTIONS EFWINSLOW.COM