HomeMy WebLinkAboutBLDP-2-005684 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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="�,.� CITY YARMOUTH MA DATE f �' %�/ '4.O*-D'r ^"4
JOBSITE ADDRESS 37 PAWKANNAKUT DRIVE OWNER'S NAME REAULT,ROBERT I
POWNER ADDRESS SOUTH YARMOUTH TEL 860.989.5981 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 1-1 EDUCATIONAL s ' RESIDENTIAL El
PRINT
CLEARLY NEW: , RENOVATION:b_ REPLACEMENT:2_1 PLANS SUBMITTED: YES 0 NO
FIXTURES 1 FLOOR-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB - °. _ nE : In:
CROSS CONNECTION 0 DEVICE ,
DEDICATED SPECIAL WASTE SYSTEM I {
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM ' �,
DEDICATED WATER RECYCLE SYSTEM M,--'F,--W ' 1 _ _ g I a .
DISHWASHER _
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FOOD DISPOSER
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TOILETSERVICE/MOP SINK
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WATER HEATER ALL TYPES 1
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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 El NO [
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY •
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 ,_.1
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are truer 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 li '�gwith II ertine proyisioryof the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \\��/// Y .t ,-.-o!/,�._�-
- - I SIGNATURE
PLUMBER'S NAME[STEPHEN WINSLOW LICENSE# 12298
MP v JP Li CORPORATIOND#I 3281C IPARTNERSHIPLJ#( I LLC # ._.._•• __._
COMPANY NAME( E.F.WINSLOW PLUMBING&HEATING 1 ADDRESS 18 REARDON CIRCLE J✓
CITY'SOUTH YARMOUTH I STATE I MA I ZIP 102664 ( TEL 1508-394-7778 k3C
FAX 1508-394-8256 I CELL N/A EMAIL I INSPECTIONS@EFWINSLOW.COM
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The Commonwealth of Massachusetts
--- Department oflndustrialAccidents
-. Office of Investigations
: = \'\ Lafayette City Center
Magri� � 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.❑■ 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 7. ❑ 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]** 1 l.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
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#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: r --4, ......b.,-•— 01/02/2020
Date:
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 #
'suing Authority(check one):
Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board
Selectmen's Office 6.['Other
person: Phone#:
www.mass.gov/dia