HomeMy WebLinkAboutBLDP-18-003294 ,
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=4! ' CITY MA DATE / PERMIT#
JOBSITE ADDRESS I LC i Ve� _
OWNERS NAME /.) /95
IP z --
OWNER ADDRESS 3 TEL N8 a-c512FAX -
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL LJ RESIDENTIAL L
PRINT PLANS SUBMITTED: YES[ NOD
CLEARLY NEW: RENOVATION:1 REPLACEMENT:1
FIXTURES 1 FLOOR--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB MINN= -- =IIIII MMINNIM®IIIIF-T,®®IIIII
CROSS CONNECTION DEVICE I —:(-,__....:_I -, -:-_:I: '1=:.. = I '�®®®®r ®®I
DEDICATED SPECIAL WASTE SYSTEM I I-__._-_:.`®E--__4L ®® �®�-- °®®�
DEDICATED GASIOILJSANDSYSTEM [_-_INN --.®C . (_ _,= �®® m �� 1--- 7Mil
DEDICATED GREASE SYSTEM I_:-_r-_iNNE-®®1==-•-` ®®� _L
DEDICATED GRAY WATER SYSTEM r:�_.iI_. rJy C�_ no ®��1 1 ,
DEDICATED WATER RECYCLE SYSTEM I !17 ®®r � ®® I r- � '
DISHWASHER - �
DRINKING FOUNTAIN FTT r I--= -MI- ®® ® --- __
FOOD DISPOSER I;_-_=. ----I _ - - �- r I
INTERCEPTOR OR(INTERIOR) (_ =-.! I - I - I- -r _ '�= - ®I—` �1 M
KITCHEN SINK I• - ®® ®®®®® —� [ �
LAVATORY r=T- 1-__ L_. 1I_�- L_ I- _�~ h--_,C-=-:_E-_
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ROOF DRAIN —T I. : - I.� r�.-ll I---I.. ..._
SHOWER STALL L___t r ®n.-1---- ® ®®® I I rii—I ----
SERVICEIMOPSINK IT—!..-- I_ FT- - 1[-- ® 'Unlit. I ,EI��
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TOILET I - 1�1MNi- _C-_.L-
URINAL I—__ ®®I ®I .r ...___,______1__ - I E—�I
WASHING MACHINE CONNECTION ® ®I ._,. I-_'®®I ®r -ll L -1�_
WATER HEATER ALL TYPES I ,__ .� I:�---�.I ®®®®I ��—
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WATER PIPING -_-.,__�_ I ._ I ®�
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OTHER I�-_-_�-_�_--_._ -_,�._,-C , —°®®�, ®1I _ -
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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 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY
El OTHER TYPE OF INDEMNITY El BOND
WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the tN
Prc
OWNER'S INSURANCE Massachusetts General Laws,and that my signature on this permit application waives this requirement. Q
CHECK ONE ONLY: OWNER [l AGENT 0
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 comp nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C
PLUMBER'S NAME STEPHEN A.WINSLOW _ ALICENSE# 12298 SIGN TURE______----- ,
MP 13 JP CORPORATION 0# 3281C PARTNERSHIP[i# —1LLCI #_
COMPANY NAME 1 EF WINSLOW PLUMBING&HEATING -j ADDRESS 8 REARDON CIRCLE
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_ I STATE MA ZIP 02664 ' TEL 508-394-7778
CITY SOUTH YARMOUTH ._
FAX 508 394-8256 1 CELL NIA _ EMAIL I accountspayable@efwinslow.com /
A
The Commonwealth of Massachusetts
;+1j�1 G Department of Industrial Accidents
riig':Er . 1 Congress Street,Suite 100
Boston,MA 02114-2017
••_' www.mass gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH ME:PERMITTING AUTHORITY.
Applicant Information
Please Print Le lbly
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 IC) employees(full and/ 5. 0 Retail
or part-time).*
2.0 I am a sole proprietor or partnership and have no 6. ❑Restaurant/Bar/Eating Establishment
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
no employees.[No workers'comp.insurance required]*
10.0 Manufacturing
4.❑ We are a non-profit organization,staffed by volunteers, 11 ®Health Care
with no employees.[No workers'comp.insurance req.] 12.0 Other
*Any 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#I.
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:23 COMMONWEALTH AVE
City/State/Zip: CHESTNUT HILL, MA 02467
Policy#or Self-ins.Lic.#1821A
Expirationate:
1/2
Attach a copy of the workers'compensation policy declaration page(showing the policy nu ber0and expiration date).
Failure to secure coverage as required under Section 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$250.0oaAdayagainst 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 cert the a' s and enalties o perjury that the information provided above is true and correct.
Si nature: `' ,--,.__1 r /--:. / /.—..�a.,.._.. Date: i _ t 3 f I
Phone#:508-394-7778
Official use only. Do not write in this area,to be completed by city or town official
City or Town:
Issuing Authority(circle one): Permit/License#
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person:
Phone#:
www.mass.gov/dia