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Home My WebLink AboutBLDP-16-006640 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I. � CITY 411Y?cJ1NI) _ MA DATE • PERMIT# �' , ° 4-ad 6& 0 JOBSITE ADDRESS fbs 1012 111f OWNER'S NAME difA I . / A '. di POWNER ADDRESS , '&V4 7 TEL '-; FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL Li RESIDENTIAL PRINT \ CLEARLY NEW:L RENOVATION:Li REPLACEMENT:cir PLANS SUBMITTED: YES Lj Novi -^ FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB MM.MI MIK MN IIIIIIII 111111111111111/1111.111.11111111111 NM NM I CROSS CONNECTION DEVICE win mum NE NMI MN 11111111 MK mai MR ON MI MK NM DEDICATED SPECIAL WASTE SYSTEM 11111.01111111111111.1111 MB INN NE IMF 11111.111.N'MK N UK M' \ DEDICATED GAS/OIUSAND SYSTEM NM NMI 111115 O DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ' � _ IM■�r -nIt,� ,_ :`fir�MM Ir _ �� ). DEDICATED WATER RECYCLE SYSTEM INni._._ ; m i ; am DISHWASHER iIt DRINKING FOUNTAIN 11111 NM FOOD DISPOSER ,, . FLOOR/AREA DRAIN € INTERCEPTOR(INTERIOR) 'I KITCHEN SINK _ i LAVATORY ROOF DRAIN r , SHOWER STALL SERVICE I MOP SINK ' TOILET IIIIIIIMIIINIIUIIIIIINNIIIII_.._ _. . MI 1.11.1111.1 URINAL WASHING MACHINE CONNECTION ONI alli 111101111.11111111111110 i um,am WATER HEATER ALL TYPES MN 1.11111111111M11111111111111,111111111111111 imi � _ _, OTHER 111 1.11111111.1.110110111011111111. IIMIIINIIIIIIINIIMIIIINMIIIIIMIIIIMIIIIIIIOIIIINIIIIIIIIIIIIIIIIIIIIIIIIIIEINPIIIIIIIRIIIIIINIINXIINIIIINIIIIIIIINIIIIIIIIIMIII 111111.111111=1.11111 _.._ M INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES r�11 NO U IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I i OTHER TYPE OF INDEMNITY L 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 L. ! 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 corn ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I 6 / PLUMBER'S NAME j STEPHEN A WINSLOW_ LICENSE# p12298 y, SIGNATURE MP`,d JP Li CORPORATION # 3281CPARTNERSHIPQ# LLC #F- `— COMPANY NAME I E.F.WINSLOW PLUMBING&HEATING—i ADDRESS 8 REARDON CIRCLE 3 CITY SOUTH YARMOUTH STATE pnikl ZIP 102664 _.... TEL 508 394 7778_._ FAX L508-394-8256 !CELL EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM SV The Commonwealth of Massachusetts • ,_= Departnanru!Industrial Accidents l Office of Investigations y 1 Congress Street,Suite 100 d Boston,MA 02114-2017 vx www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individuaq: E. F.WINSLOW PLUMBING&HEATING CO.,INC. Address:8 REARDON CRCLE City/State/Zip:SOUTH YARMOUTH,MA 02664 Phone#:508-394-7778 Are you an employer?Check the appropriate box: Type of project(required): 1.0 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 2.❑I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.: required.] 5.❑ We area corporation and its 10.0 Electrical repairs or additions 3.❑I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c.152,§1(4),and we have no 13.❑Other employees.[No workers' comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees.If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic.#:1794 A Expiration Date:01/01/2016 Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations oft IA or surance'co erage verf•tion. I do hereby cert0,un a ins and enalties %erjury that the information provided above is true and correct 2016 Signature: /�� 'L Date: Phone#: 508-394-777 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: '"'" "—Phone#: