Loading...
HomeMy WebLinkAboutBLDP-19-000339 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK = CITY/TOWN YARMOUTH MA DATE 07/11/2018 PERMIT# /l✓,P/7'407 JOBSITE ADDRESS 18 CREST CIRCLE OWNER'S NAME PILLING OWNER ADDRESS WEST YARMOUTH TEL 774-219-5534 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: [' PLANS SUBMITTED: YES❑ NO 12 FIXTURES Z FLOOR—* 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 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 ALL TYPES 1 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ed NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY EV' OTHER TYPE OF INDEMNITY El 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. 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. ue 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 c liance with all Pertinent� provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# 12298 - SIGNATURE MP g JP❑ CORPORATION [/'# 3281C PARTNERSHIP❑# LLC❑# COMPANY NAME EF WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL accountspayable(u�efwinslow.com 4760073 $50.00 C-✓' tit Department of InttustrialAlccaaenrs N//t-- -1//3/c, )•=' jP.,gr1 ©,fficeof'Investigations _:!'_t 600 Washington Street .; =I Boston,MA 02111 t�, ' www.rnass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Buslness/Orgenization/Individual):e.c•Wtr\5t0,,,, Q(Vw.6i✓rccl(J L ti<.Q\--/ `®.,ieiC. Address: S. (4.o tern Cyrate- . City/State/Zip: Soo Irh icr v."0...,k's MPr Phone#: "506-3cl`1-11? Are you an employer?Check the appropriate box: Type of project(required): 'Ti am a employer with -70 4.0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time)." have hired the sub-contractors ;.❑I am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'camp.insurance 5.0 We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their of exemption per MGL I1.❑Plumbing repairs or additions V.❑I am a homeowner doing all work rightP myself.[No workers'comp. c.152,§I(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] lily applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site formation. lsurance Company Name: A Yp•..•} f i kta ..L.il v"Cj C am`) . olicy#or Self-ins.Lic.#: \/5 a.1 Pr Expiration Date: s-1- 01017 tb Site Address: 3 COrwoon n Q 0-)` 1 C0 ' ,'M" City/State/Zip: O0)y b7 ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a ne 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 Cup to$250.00 a da a:ainst the violator.Be advised t at a copy of this statement may be forwarded to the Office of tvestigations. the DIA for insurap verage veri a on. ( do hereby certify un e e sins a penalties of pe jury that the information provided above is true and correct. i�t. 4./A Date: (-a.)3 I 1 a.01 r hone#: .S1lR:35`1,777X 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: