HomeMy WebLinkAboutBLDP-20-005999 K0AGGACHUSETTSUN|R5RM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY YARMOUTH _ � MA DATE iPERN[T# N, M-WrR 7
- JOBSITE ADDRESS 23O WEIR ROAD. _ _ J OVVNER'SNAMEFLETCH
l�� 0�NERADDRESS YARM0UTHp0RT | TEL 5O8�6O�798 FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONALN RESIDENTIAL�
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: j PLANS SUBMITTED: YES::] NON
FIXTURES-1 FLOOR- Bnm 1 2 3 4 5 0 7 V 9 10 11 12 13 14
BATHTUB
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CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
JIM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
71
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL F_
SERVICE MOP SINK
TOILET
URINAL 4
WASHING MACHINE CONNECTION
NOW jW
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
|have m current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO F!
|F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 8Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OFINDEMNITY 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 / J AGENT �]
SIGNATURE OF OWNER ORAGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application
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PLUMBER'S NAME STEPHENVV|NSLOVV LICENSE 12298 SIGNATURE
mP�� JP�l CORPORATION PARTNERSHIP[
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COMPANY NAME[ EFVNNSLOVVPLU�B|NG&HEATN� ADDRESS 8REARD8NCIRCLE
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CITY! K]UTHYARMOUTH STATE[— � ZIP 02664 TEL 5O�004�778
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FAX CELL N/A EMAIL hNSPECT|ON
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The Commonwealth of Massachusetts
Department oflndustrialAccidents
x l ' Office of Investigations
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3 Lafayette City Center
IliP 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 10.0 Manufacturing
no employees. [No workers' comp. insurance required]** 11.0 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 i• y-tenef the ins
and penalties of perjury that the information provided above is true and correct.
Signature: \```JJ�, T "` - '-'" Date: 01/02/2020
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):
1.0Board of Health 2.❑Building Department 3.❑City/Town Clerk 4.❑Licensing Board
50 Selectmen's Office 6.['Other
Contact Person: Phone#:
www.mass.gov/dia