HomeMy WebLinkAboutBLDP-20-006316 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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� CITY 1 MA DATE /S,Z2O PERMIT# J344,2i - 'e 'L'6 6 V -
JOBSITE ADDRESS I 61 QVaf k /4 .1( Row F OWNER'S NAME IOl'L✓1CRII
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OWNER ADDRESS 5Qg1�135 9_3 3 I FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL( -] EDUCATIONAL 0 RESIDENTIAL L—
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CLEARLY NEW:[- RENOVATION:L I REPLACEMENT: PLANS SUBMITTED: YES 0 NO
FIXTURES 1 FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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CROSS CONNECTION DEVICE s _i 'I �
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DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEMI -'� __..'_
DEDICATED GREASE SYSTEM
I DEDICATED GRAY WATER SYSTEM I -E [ i rJr i f{ iI _r En__ , it--[--[
DEDICATED WATER RECYCLE SYSTEM I I I._ 1 , i(" ?I- -.,. .. ' 1C-...,.T- ' ' ...--TC..,.....IL-7 --a�..
DISHWASHER I 'C _ T ,7 �{- >I.. ._�'r ..II-.. . - . [_--- -w....{v, --T-.. , ._ w.l �._._(
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FOOD DISPOSER
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WATER HEATER ALL TYPES f --
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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[] NO I ]
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY[1 OTHER TYPE OF INDEMNITY f BOND L-
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 n AGENT 11,I
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 it e to the b t of my knowledge
v.,.— and that all plumbing work and installations performed under the permit issued for this application will be in corn lia with II ertine proyisio of the
C.,. C< Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
r PLUMBER'S NAME[STEPHEN WINSLOW ...4.LICENSE# 12298 ) SIGNATURE
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, MPH JP[ CORPORATION S#E3281C JPARTNERSHIPf# LLC 1#
COMPANY NAME I E.F.WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE
CITY(SOUTH YARMOUTH I STATE I MA } ZIP 102664 I TEL 508-394-7778
FAX 1508-394-8256 I CELL I N/A I EMAIL INSPECTIONS@EFWINSLOW.COM
The Commonwealth of Massachusetts
Department of Industrial Accidents
113`" Office of Investigations
Lafayette City Center
2Avenue de Lafayette,Boston,MA 02111-1750
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i/� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le.ibly
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):
1.0 I am a employer with 90 employees (full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no
7. El 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 10.0 Manufacturing
no employees. [No workers' comp. insurance required]**
4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box 41 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 41.
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. #1909A Expiration Date:01/01/2021
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 ' e the ins and penalties of perjury that the information provided above is true and correct.
Signature: /i' h/- °4� 01/02/2020
� 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):
1.0Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.0 Licensing Board
50 Selectmen's Office 6.DOther
Contact Person: Phone#:
www.mass.gov/dia