HomeMy WebLinkAboutBLDP-20-5365 MASSACHUSETT,�SS,,U� v1 UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING
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CITY Y4_1(M0-1 1' 1 MA DATE J .L./JOJPERMIT# ji "ffd
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INSURANCE COVERAGE:
t I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO I
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('iy IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
er" LIABILITY INSURANCE POLICY Ed OTHER TYPE OF INDEMNITY Q 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 Li 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 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 co lia with II ertine prqisio2,of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE
MPLI JP® CORPORATIONQ# 3281C PARTNERSHIP®# LLCQ#
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING I 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
w isoDepartment of Industrial Accidents
L
Office of Investigations
t _ Lafayette City Center
MOW = 2 Avenue de Lafayette, Boston,MA 02111-1750
s'`y 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. El 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]** 11.❑Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
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 cera the ins and penalties of perjure that the information provided above is true and correct.
01/02/2020
Signature: .:.,»il
"` •,."--- Date:
g � � e.
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 31:1 City/Town Clerk 4.❑Licensing Board
5.0 Selectmen's Office 6.❑Other
Contact Person: Phone#:
www.mass.gov/dia