Loading...
HomeMy WebLinkAboutBLDP-20-005583 Mla �' oddw :N — LfI3 - 41SS - 73 g5 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK % . ' x CITY L la 1r( t MA DATE Lil i/D'O I PERMIT# ?P-Ao r a JOBSITE ADDRESS IS PILq}tpp C4-_ t4). 7 Ing2AltizWNER'S NAME[/ (14,24 4-exact)/el POWNER ADDRESS i.I Otd. Ctrm Pa•ri-otareAdat, MA ak/13531vig IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL u RESIDENTIAL®' PRINT '• CLEARLY NEW:LI RENOVATION:[-1 REPLACEMENT:Er PLANS SUBMITTED: YES lj NOLI FIXTURES 7 FLOOR--I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE LI ' DEDICATED SPECIAL WASTE SYSTEM �,,.r l �r i DEDICATED GASIOIUSAND SYSTEM I I DEDICATED GREASE SYSTEM jL ®� t DEDICATED GRAY WATER SYSTEM � '11111 M M DEDICATED WATER RECYCLE SYSTEM M DISHWASHER FOOD DISPOSER MI FLOOR/AREA DRAIN mMJW®jm_� t) INTERCEPTOR(INTERIOR) XII r Nis sim �1 I_m��II 14 3 KITCHEN SINK ��� ®j®I®j LAVATORY NM 1111111 W----- ROOF DRAIN I il - SHOWER STALL NMINEIN SERVICE I MOP SINK ' —1a -- TOILET r !IIIIMIt URINAL im. '� - rx WASHING MACHINE CONNECTION NM ��= � '� _ I ..., WATER HEATER ALL TYPES MR O WATER PIPINGi_ OTHER a - - ___ _ .' ' a �M. _ _________ ,,......... - !.... � - � � �� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO Li IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY Li BOND Li 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 ID AGENT Q 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 cor�plia with yertine pro'isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r � ...p _ PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MPO JP© CORPORATION0# 3281C PARTNERSHIPQ# LLCI. .1# COMPANY NAME' E.F.WINSLOW PLUMBING&HEATING 1 ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM The Commonwealth of Massachusetts "N14. ' —w== Department of Industrial Accidents —Ri ^� Office of Investigations vIaill= ' 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): 1.11] 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 7ID 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, 11.0 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. #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 ' the ins and penalties of perjury that the information provided above is true and correct. Signature: _ ` h .-.1L Y % Date: 01/02/2020 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): 1fBoard of Health 2.0 Building Department 3.0 City/Town Clerk 4.OLicensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia