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Home My WebLink AboutBLDP-20-002705 / (P MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �8 EV CITY L3 .7nir7-�w..i MA DATE/fr / PERMIT n, JOBSITE ADDRESS 1/7/c1r,1/ )( el aga( g OWNER'S NAME' GC-OJZG_L" t-tL'' P OWNER ADDRESS - D j .. , .1 l�R�-s`�,1✓, .��c� i.�f�'.f �� .. � TEL',5a5i/ ,.�36 . FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL RESIDENTIAL, PRINT CLEARLY NEW: RENOVATION:[, REPLACEMENT:N PLANS SUBMITTED: YES[ NO[ FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ,_.._____-if CROSS CONNECTION DEVICE —�'F "� z DEDICATED SPECIAL WASTE SYSTEM Y' DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM ; DEDICATED GRAY WATER SYSTEM - ''-- - DEDICATED WATER RECYCLE SYSTEM "` s' DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY .1 -*w: ROOF DRAIN -= SHOWER STALL II �1 SERVICE/MOP SINK - -1 TOILET / _ .�L URINAL �\ WASHING MACHINE CONNECTION w �.. WATER HEATER ALL TYPES WATER PIPING OTHER Y ,ti, a_ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E NO ( IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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 applica ion 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 wil' e in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.— 7 _._..__.._ _ Z Lyctie.ti PLUMBER'S NAME STEPHEN A.WINSLOW j LICENSE# 12298' SIGNATURE MP i JP. 3 CORPORATION, #[3281C (PARTNERSHIP) ,J#L ILLC # COMPANY NAME LE F WINSLOW PLUMBING&HEATING ADDRESS}8 REARDON CIRCLE CITYLBOUTH YARMOUTH __ _ _ STATE MA ZIP 02664 I TEL 1.98-394-7778 FAX '508 394-8256 CELL I N/A 3 EMAIL I ACCOUNTSPAYABLE EFWINSLOW,COM -ad �� a - �c ` 7- The Commonwealth of Massachusetts _;Ap=5 Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance AtTidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibltr Name(Business/Organization/lndividual):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?Cheek the appropriate box: Type of project(required): I ID I am a employer with 88 employees(full end(or pert-time).' 7. ❑New construction 2.0 I era a sole proprietor erpartnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. Remodeling 3.0 1 am a homeowner doing all work myself.[No workers'comp.insurance required.)* 9. 0 Demolition 4.0 I am a homeowner mid will he hiring contractors to conduct all work on my property.I will )O Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employee. 12.E1 Plumbing repairs or additions 5.❑1 am a general connector and I have hired the sub-contactors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insumnce.t 13.0Roof repairs 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14•❑Other 152,11(4),and we hove no employees.[No workers'comp.insurance required.] "Any applicant that decks box Al must also fill out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. lControctors that check this box must attached an additional sheet showing the name of the sub-contractors and store whether or not those entities have employees.Hike sub-contractors have employees,they must provide their workers'comp.policy number. t am as 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.#:1909A Expiration Date:01/01/2020 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 MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,us well as civil penalties in the fort of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify urtd to pals Ind pen !ties of perjury that the information provided above is true and correct Sig nature: •f „/( 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# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: