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Home My WebLink AboutBLDP-18-007132 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w�—- YARMOUTH 06/122018 PERMIT#,ram-.r+r�L��f1PCB 7/�,g CITY/TOWN MA DATE JOBSITE ADDRESS 17 SOUTH STREET OWNER'S NAME MURPHY,KATHLEEN OWNER ADDRESS SOUTH YARMOUTH TEL 508-398-0761 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL) PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:® PLANS SUBMITTED:YES 0 NO E FIXTURES 1 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 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 g NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE E TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E6 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. 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 true 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 complia 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[if JP 0 CORPORATION 12# 3281C PARTNERSHIP 0# 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 accountspayableWiefwinslow.com WORK ORDER 475133 550.00 AR f *_� Department of industrial Aitccacaenrs ;- ► Office of Investigations lli� t= 600 Washington Street c. Boston,MA 02111 • www.Pnass.gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information i Please Print Legibly Name(Business/Organization/Individual): ��.W i,r3 Qv.) Q(khN,lowtcl Q 1-)QQ\-r r c 1 dIC, Address: i\k>o ttsn City/State/Zip: Soo h �j c�w�c,.• t�P Phone#: 501i- V-1,1 T7 . Are you an employer?Cheek the appropriate box: Type of project(required): ,, I am a employer with -70 4. ❑ 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,$ 1. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. El We area corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions I.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required]t employees.[No workers' 13.❑Other comp.insurance required.] .ny 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 end 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 sub-contractors 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.tsurance Company Name: Arrb. : 1—Urt/o.Ai 3 Scsrc& olicy#or Self-ins.Lic.#: $a 1 A Expiration Date: f—] -- aot`- )b Site Address:D 3 cv o-wcrn,, o 1 t )h1-y OAQ 414 n\\ City/State/Zip: C3- 4 i t 7 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 f up to$250.00 a d against the violator. Be advised twat a copy of this statement may be forwarded to the Office of tvestigations 1 the DIA for insuranea overage verif1c t on. do hereby certify tind'er e ants anapenalties of peijuiy that the information provided above is true and correct. ignaturei- 7 _ Date: f� 31 a01, hone#: 77X 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): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other . Contact Person: Phone#: