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HomeMy WebLinkAboutBLDP-18-005478 S� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 7� W—= PERMIT#rn____4��$ 'E �O MID MA DATECa=e=. CITY ' *�. �' ~� OWNER'S NAME ->v� - -v-.�a �- JOBSITE ADDRESS Ii !1 C X t - ID OWNER ADDRESS '� TEL AXE TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL[_] RESIDENTIAL 41--- PRINT PLANS SUBMITTED: YES[ NO f[� CLEARLY NEW:® RENOVATION:0 REPLACEMENT: FIXTURES 1- FLOOR-3 D0©©0© 6INal 9 io ��®� q. BATHTUB I_ _v �®® ®� ® ;'�^ DEDICATEDCROS CONNECTI WASTE SYSTEM VICE �_ I ® ® `Wp, SPECIAL DEDICATED GREASESAND SYSTEM [ —I® �������®®®� -� DEDICATED GREASE SYSTEM ®® �®®�®® DEDICATED GRAY WATER SYSTEM M��� r�® ��®® DEDICATED WATER RECYCLE SYSTEM ®®®M �®� M�® [�® DISHWASHER FOODDGFOUNTAIN - ®�®®®®®�®�®�� FOOD DISPOSER ® '� FLOOR I AREA DRAIN -��®®®®�� ®® INTERCEPTOR(INTERIOR) ���®® ®®IMI®NK��� LAVATORY ®�®®®®���® ®� ROOF DRAIN ®®®®® SHOWE R STALL ®®®NII®®®INUIPINEWININIONIN ®®®� SERVICE I MOP SINK ®®�������®®®®®� TOILET ®®�®®�®®®M®®®® URINAL WASHING MACHINE CONNECTION (�® ®®®�®®®�� WATER HEATER ____ES wo®�®�����N�®��� WATER PIPING_. ® cs OTHER — =c-- ,MI®MINIII ®IIMM L-- �_ `- _ INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES LITI NO I:� IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHERTYPE OF INDEMNITY 0 BOND U OWNER'S INSURANCE WAIVER:I am rsit naatuhelon thise does not application waives this requirement.ave the insurance coverage uired by Chapter 142 of the Massachusetts General Laws,and thatmy 9permitAGENT { CHECK ONE ONLY: OWNER SIGNATURE OF OWNER OR AGENT • 1 herebythat all plu that allof the details ia and llations performed under the permit Issuedrmation I have submitted or for hisding thls applic application be in cation are true and accurate to the best of my with all Pertinent provision of theedge and that all plumbing work and Massachusetts State Plumbing Code and Chapter 142 of the General Laws. SIGNATURE PLUMBER'S NAME STEPINSLOW ��� 12298 LICENSE# m MPU JP® CORPORATIOND 3281C PARTNERSHIP©# LLCI:1# _________ COMPANY NAME ING&HEATING ADDRESS 8 REARDON CIRCLE T�— TEL 508-394-7778 �.�--- CITY SO ARMOUTH J STATE MA I ZIP 02664 FAX 50808-3 1 CELL NIA 1 EMAIL I accountspayable@eivdinslow.com �— A Th�Ge Commonwealth o.>`'�Ylassa_chusetts Department oflndust>^ialAccidents 1 Congr ess gressStreet,Suite 100 Boston,MA 02114 2017 I ul°' Workers'compensation mass.gov/dza onInsuranceAffdavit:general Businesses. A licant Information TO BE FILED WITH THE PERivIITT1NG AUTHORITY. f Domensati Business/Organization Name:E.F.WINSLOW PLUMBING&HEATING CO.,INC Please Print Legibly Address:8 REARDON CIRCLE City/StateyZip:SOUTH YARMOUTH,MA 02664. Are you an employer? Phone#:5983947778 Check the appropriate box: 1.0I am a employer with. Business Type(required): or part-time).* employees(full and/ 5• Retain 2• I am a sole proprietor or partnership 6. QRestauranf/B ar/Eating Establishment employees working for me in anycapacity.and have no • [No workers'comp.' y' EI Office and/or Sales(incl,real estate,auto,etc.) p insurance required] 3 0 We are a corporation and its officers have exercised 8. 0 Non-profit their right of exemption per c.152,§1(4), 9 ❑Entertainment [No workers co ()'and we have no employees. , 4•❑ We area non-profit organization, insurance required]*` 10.0 Manufacturing with nore employees. ganization,staffed by volunteers 11•❑Health Care P yees.[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 policyinfo **lithe organization corporate officers have exempted themselves,but the corporation has other employees,a organization should check box#I. information. workers'compensation policy is required and such an X am an employer that is providing workers'compensation UR insurancefor my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY COMPANY Insurer's Address:23 COMMONWEALTH AVE City/State/Zip: CHESTNUT HILL,MA 02467 Policy#or Self-his.Lie.#1821A Attach a copy of the workers'compensation policy declaration page(showing the olio Expiration bate:01/01/201 Failure to secure coverage as re p y number and expiration date). required under Section 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 of up to$250.00 a dayY imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine against the violator. Be advised that a copy of this statement may be forwarded to the Office o Investigations of the DIA for insurance coverage verification. Idolterebycerti rthe a• f and enalties o perjury that the information provided above is true and correct Si afore: Phone#:508-394-7778 �� Date: ) I l L Official use only. Do not write in this area,to be completed by cl tY or town officialCity or Town; Issuing Authority(circle one): Permit/License# 1.Board of Health 2.Buildingllepartment 3. 6.Other City/TomCIerk 4.Licensing Board 5.Selectmen's Office Contact Person: Phone#: www.mass.goy/dia • •