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HomeMy WebLinkAboutBLDP-18-006285 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY [YARMOUTH MA DATE 5/8/18 PERMIT# BLDP-18-006285 JOBSITE ADDRESS 10 MARSH POINT OWNER'S NAME REBECCA&THOMAS KILLION P OWNER ADDRESS 406 JAYSTONE COURT BOWIE,MD 20721 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m PRINT CLEARLY NEW 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOORS—. BSM 1 2 3 4 5 8 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK 1 TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0 • ' 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 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are sue 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Tygue Reed LICENSE#5200 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME TYGUE S REED ADDRESS 78 SANTUIT POND RD CITY MASHPEE STATE MA ZIP 026492421 TEL FAX CELL EMAIL lisa©coastalphc.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES • Yes Na e THIS APPLICATION SERVE AS THE 0 0 OCOYIT FEES$ PERMIT* PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • c� 01 wears • a"'-��i1_ CITY Yarmouth Port MA DATE 05/08/2018 PERMIT#r g22'(re JOBSITE ADDRESS 10 Marsh Point OWNER'S NAME Rebecca and Thomas Killion POWNER ADDRESS 406 Jaystone Court-Bowie,MD 20721 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL D PRINT CLEARLY NEW:❑ RENOVATION:Q REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM 1_ ,. . DEDICATED GAS/OIL/SAND SYSTEM I -T DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 1, . DISHWASHER 1 __.. DRINKING FOUNTAIN -- FOOD DISPOSER FLOOR/AREA DRAIN . INTERCEPTOR(INTERIOR) KITCHEN SINK I LAVATORY _ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION d —I, WATER HEATER ALL TYPES - WATER PIPING — _ _ _ OTHER _ A _ r—t __ . _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY 0 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 ❑ 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 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7,7re 4.Pe oma! PLUMBER'S NAME Tygue S Reed LICENSE# 15200 p, SIGNATURE MPD JPD CORPORATION 0# PARTNERSHIP❑# LLCD# 4047C COMPANY NAME Coastal Mechanical ADDRESS 299 Whites Path t_ CITY South Yarmouth STATE MA ZIP 02664 TEL 50643,-14-4A-; 'LIVED FAX 508-760-5800 CELL 508-246-9959 EMAIL I lisa@coastalphc.com MAY 8 2018 , ,49F i `"T.DEPA... ENT' The Commonwealth of Massachusetts -. =rim=— Department of Industrial Accidents _ t Office of Investigations • P : 1= 600 Washington Street • -'!7 Boston, MA 02111 ^•�,• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Coastal Mechanical Address: 299 Whites Path City/State/Zip: South Yarmouth, MA 02664 Phone #: 508-737-8747 Are you an employer?Check the appropriate box: Type of project(required): 1. ✓ 1 am a employer with 15 4. 1 am a general contractor and I ✓ employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. ✓ Remodeling ship and have no employees These sub-contractors have 8. Demolition workingfor me in anycapacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp.insurance.: required.] 5. We are a corporation and its 10.✓ Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. ✓ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. ✓ Other 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. =Contractors 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: Liberty Mutual Policy#or Self-ins.Lic.#: XWO1857754371 Expiration Date: 01/04/2019 Job Site Address: 10 Marsh Point City/State/Zip: Yarmouth Port, MA 026 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 24.142.41.0-. /1/B�,/LI1i Date: 05/08/2018 Phone#: 508-737-8747 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#: Client#:764315 2COASTALPLI ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 01/09/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS ' CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Dowling&O'Neil Dowling&O'Neil insurance Agy PHONE 508 775.1620 F^X 5087781218 (A/C,No,Ext):508 No): 973 Iyannough Road E-MAIL doins.com P.O.Box 1990 ADDRESS: col@doins.com INSURER(S)AFFORDING COVERAGE NAICp Hyannis,MA 02601 INSURER A:ohlo security Noumea Company 24082 INSURED INSURER B:Milo Casually Group Coastal Plumbing&Heating LLC 299 Whites Path INSURER C: South Yarmouth,MA 02664 INSURER O: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE JNSR WVD POLICY NUMBER (MM/DDIYYYY) (MMIDD/YYYY) LIMITS A GENERALLIABILm' BINDER443200 01/04/2018 01/O4/2019 EEpAApCt�HHq��OEECTCTppURgqRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Eaoccun°nee) $300,000 ICLAIMS-MADE a OCCUR MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEM.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2,000,000 fI -1 POLICY I JECT IT LOC $ AUTOMOBILE DASIUTY COMBINED SINGLE LIMIT (Ea aaident) S ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident $ _ AUTOS _ AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION S $ B WORKERS COMPENSATION XWO1957846378 01/04/2018 01/04/2019 X wcsTATu- I DTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 51,000,000 DeSsCRPOeN uOF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,II more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained In the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 134 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE .91 gegafd. frig ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S204532/M204528 RPJZ1 # . . . COMMONWEALTH OF MASSACHUsETTS ,-•-t, • ,,;..MIXDIVisioN,OFiPROFESSiONALMCEisiSUFIEMBOARDOF . * PLUMBERS.AND GASFITTERS ••'',II I...: I `‘; ISSUES THE FOLLOVVING LICENSE 1 < . ... •' ftEGISTEREDPLUMBING CORP Ihc I -1, 4 . „ TyGuE S REED l' • in I COASTAL PLUMBING&HEATING, LLC .i 9 MEUSSA AVE ..'',, .;I...J a i MASHPEE,MA 02649't..I'' 4047!., ;.,.,'I%, 05/01/2020..... •ILII 458838 ' • • . . .:i itoMmONWEALTH OF MASSACHUSETTS : y . . v., SoivisiontoFiFROFESsioNALMICENsUFIM.1 , BOARD OF . I' . . .., PLUMBERS AND GASFITTERS ' '•'II .. . . ISSUESTHE FOLLOWING LICENSE . . ,... , .. . . • • . . A•- ..- ,..MASTER PLUMBER • „TyGUE S REED . ,.., . . - •• .• ,,c.'i: '.e MELISSA SVE sic ,t16.: lir lia-, - • MASHREE,MA'02649-2132 -Avk,,:! I . .,k • . • . . . . '.'s,•,, .. . kNsib.. ! • II 1520a 'I.;I'05/01/2020, 'I 458839 . . . . . . .. . . . . . . . A. . . .. . COMMONWEALTH OF MASSACHUSETTS * -ItilDIVISION'OPFROFESSIoNAC.cLICENSURE101 I v...T. „.:. , • ..-,BOARD.OF • PLUMBERSAND GASFITTERSIII;II,IiI I • I ISSUES THE FOLLOWINGUCENSE .,... iI..;:".':iouRNEvmAti a.umBER D j ,TYGUE S REED 'A.' •• . ik.... I.-I II..9 MELISSA AVgI MASHPEEI.MA,02646-212;„I,I;;;;:"Irk. ., . ILT, I • ., k., i 26447 II':V Yosioupp„,, ,.-, 458840 Iw'i . , . . . .