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Home My WebLink AboutBLDP-20-003229 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK lii ` —I- '1.t-�., CITY __ 1 ,-'177(, MA DATE 1111Waill PERMIT# llaP'Ve-CV 3zI JOBSIT ADDRESS Imo, l � , 3'i OWNER'S NAMELJ_c -, I POWNER ADDRESS F 12 .__ _ TELI`l(;_,"l6' ' ( - FAX ___ _ _ .., TYPE OR OCCUPANCY TYPE COMMERCIAL[) EDUCATIONAL D RESIDENTIAL ( - PRINT CLEARLY NEW:® RENOVATION:® REPLACEMENT: -- PLANS SUBMITTED: YES® NOQ FIXTURES 1 FLOOR-; BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB illilli _-- CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM I DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ 1 i__ _ `— jl're __ DEDICATED WATER RECYCLE SYSTEM �� rr �- T DISHWASHER_ --- --- - - I 1 DRINKING FOUNTAIN V FOOD DISPOSER f 01 - I _-1 l� FLOOR./AREA DRAIN __ INTERCEPTOR INTERIOR) I 1.___ 1-4 1 1 I LO KITCHEN SINK - :,1. _ __ _.. ____ - - LAVATORY _ i _ ROOF DRAIN SHOWER STALL Ow -_ I SERVICE/MOP SINK - I 1 TOILET -_ _- r-__ �- _ � �� -_ URINAL y — WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING . I '_ IXI OTHER M . I - r _. [ _ IIIII_ - - I. r r ' -I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY J BOND Cr OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the a. 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 application are tru nd 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. PLUMBER'S NAME STEPHEN A.WINSLOW p E L . _______..,__ I LICENSE# 12298 SIGNATURE MPQ JP® CORPORATIONQ# 3281C __PARTNERSHIP®#M LLCD# _ _-,1 COMPANY NAMEL EF WINSLOW PLUMBING&HEATING !ADDRESS 8 REARDON CIRCLE __._._______-___._-____._ .._ CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 FAX_508-394-8256 L CELL N/A _ EMAIL i accounts a able efwinslow.com I 6,9 *Q Pc) 3 4 071-- I The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia \Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):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: Type of project(required): LEI I am a employer with 88 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Ell Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. [1]Demolition 10 Q Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole nu Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.['Other 152,§1(4),and we have no 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. tContractors 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.#: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,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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and a pai s nd pen Ities of perjury that the information provided above is true and correct. Signature: 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 Contact Person: Phone#: