HomeMy WebLinkAboutBLDP-20-005889 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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MA DATE 05112/20 1 /;G PERMIT# -4' "cV� ?
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JOBSITE ADDRESS 4.08 MAIN STREET OWNER'S NAME RECKNAGEL,JUDITH
POWNER ADDRESS YARMOUTHPORT [ TEL 508.375.0918 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL, . EDUCATIONAL F. RESIDENTIAL Ell
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CLEARLY NEW: RENOVATION:L.J1 REPLACEMENT:LA PLANS SUBMITTED: YES NO[
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INSURANCEflE,... COVERAGE:
I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO Li
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 Pi
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true r e to the b t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co li with II ertine proyisio of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �\
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PLUMBER'S NAME STEPHEN WINSLOW i LICENSE# 12298 i SIGNATURE
MP JP[A CORPORATION[# 3281C PARTNERSHIP[# LC I#
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITYSOUTH YARMOUTH STATE MA ZIP 02664 1 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL INSPECTIONS@EFWINSLOW.COM
y The Commonwealth of Massachusetts
Department of Industrial Accidents
9 i Office of Investigations
;. Lafayette City Center
4 =l 2 Avenue de Lafayette, Boston, MA 02111-1750
' y 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):
1.111 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.❑ Manufacturing
no employees. [No workers' comp. insurance required]**
4.ElWe are a non-profit organization, staffed by volunteers, 11.0 Health Care
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 the ins and penalties of perjury that the information provided above is true and correct.
Signature: Y "` -.Av.—, 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):
1.1=1Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board
5.0 Selectmen's Office 6.['Other
Contact Person: Phone#:
www.mass.gov/dia '