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Home My WebLink AboutBLDP-20-002192 ., yz'i • g 7 71 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT PERFORM PLUMBING WORK m.z _—ra eg Q u. d r _ MA DATE VO��NT�., CITY � I_ ,r,�.% _ I PERMIT# �"�D'OO o7�� JOBSITE ADDRESS OWNER'S NAMES 4r130 —.V._ OWNER ADDRESS ADDRESS D oC -3 Q f,/��lckt'I/flJ0./C 4 TEL�G� '_ `a 7_, , w - .31 TYPE OR OCCUPANCY TYPE COMMERCIAL L I EDUCA110NA .(ilf RESIDENTIAL tif PRINT CLEARLY NEW: RENOVATION:7 REPLACEMENT:[)(1 PLANS SUBMITTED: YES__,.. NO FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _.._ :. ... DEDICATED SPECIAL WASTE SYSTEM Y'_�` DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM i, =r DEDICATED WATER RECYCLE SYSTEM . DISHWASHER __ DRINKING FOUNTAIN -„-, FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN .� '' SHOWER STALL SERVICE/MOP SINK _J-. TOILET URINAL WASHING MACHINE CONNECTION (_- .s WATER HEATER ALL TYPES WATER PIPING —_ u� OTHER -., ,.,.-,o,; - INSURANCE COVERAGE: I have a current liabilitLinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES J NO ill IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY-' OTHER TYPE OF NDEMNITY BOND L_I 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 SIGNATJRE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are t r and 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 co iance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4,,9 PLUMBER'S NAME STEPHEN A.WINSLOW LICENSE# ' 12298 SIGNATURE MP i JPD CORPORATION[1#[3281C :PARTNERSHIPLJ#L _„_ , LLC[ # I COMPANY NAME 3 E F WINSLOW PLUMBING&HEATING ADDRESS j 8 REARDON CIRCLE CITY SOUTH YARMOUTH _ ... STATE' MA ZIP 102664 1 TEL 508 394 7778 µ�m FAX '508-394-8256 C ELL N/A - - EMAIL I ACCOUNTSPAYABLE@EFWINSLOW.COM The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'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: LEI I am a employer with 88 employees(full and.or part-time).* Type of project(required): 7. ❑New construction 2.0 t em a sole proprietor or partnership and have no employees working for mein any capacity.[No workers'comp.insurance required.) 8•El Remodeling 3.0I ion a homeowner doing all work myself.[No workers comp.insurance required.]t 9. ❑Demolition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property.1 will II Building addition ensure that all contractors either have workers'compensation insurance or am sole I. Electrical repairs or additions proprietors with no employees. ID I am a general contractor and I have hired the subcontractors listed on the attached sheet. 12.❑Plumbing repairs or additions Mace sub-contractors have employees and have workers'comp.insurance.t 13.0 Roof repairs 6.01Ve am a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 15?,*I(4),and we hove no employees.[No workers'comp.insurance required.) Any applicant that checks box dl must also fill nut the section below showing their workers'compensation policy information. Homeowners who submit this andovit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must atmchcd an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees,lithe sub-contractors have employees,they must provide their workers'comp.policy number. /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,us well as civil penalties in the fonn of a STOP WORK ORDER and a fine of up to S250.00 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 und e pat s qnd pen fries of perjury that the information provided above is true and correct. Signature: y K'--' Date: phone#:508-394-7778 Official use only. Do not;rile 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.CityTrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: