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HomeMy WebLinkAboutP-13-775 1Z, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK it a:aw•. c. —iti# . CITY Yarmouth MA DATE 51812013 PERMIT# p/,3-775— - JOBSITE ADDRESS 16 Cozy Home Terrace OWNER'S NAME Steve Williamson P - OWNER ADDRESS TEL 508.778.6655 • FAX 508.946.5650 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL 0.i PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:D PLANS SUBMITTED: YES 0 NOD FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 I 10 11 12 13 14 BAHTUB $4 $ ( I (' CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM 1 1 �i • DEDICATED GAS/OIL/SAND SYSTEM j ,,^ ''-1".---1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ 6 t 1 1 5 DEDICATED WATER RECYCLE SYSTEM 1 DISHWASHER DRINKING FOUNTAIN _ i I FOOD DISPOSER - _ • FLOOR!AREA DRAIN INTERCEPTOR(INTERIOR) 1— Ir ( �' --__I"____ KITCHEN SINK 1 i LAVATORY . _a'-1 s.�.s. — _, -_ ROOF DRAIN SHOWER STALL 1 1 1 SERVICE/MOP SINK1 - ' 7 TOILET s l 4 I URINAL '�r- F1 r WASHING MACHINE CONNECTION P l i WATER HEATER ALL TYPES L -11Laj _ WATER OTHER 1.- ......_—______PING - '` _ -1._- I !1--___ I _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑' IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑+ 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. CHECK ONE ONLY: OWNER 0 AGENT 0 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 s- ' ->+r -te to, e best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be in compl�l7i ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i , - PLUMBER'S NAME Jeffrey Bell UCENSE# 11655 / SIGNATURE MPD JP CORPORATIOND# 3407 PARTNERSHIP❑# LLC❑# COMPANY NAME Crest Service Corp ADDRESS 12 Crest Drive I • CITY Middleboro STATE MA ZIP 02346 TEL I 508.946.9800 ___.._-..... --,--7.1 FAX 508.946.5650 CELL 781.249.9529 EMAIL mrrootersma©gmail.com to ;:: L. ` --- ��- ,Al13 2013 1 I � Jp * BUILDINGUEPART N . . . . • . miaIllag • The Commonwealth of Massachusetts Print Form N=�=— t Department of Industrial Accidents t_3'li f Office of Investigations _5 1= , 1 Congress Street,Suite 100 Boston,MA 02114-2017 �''•—.,• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansiPlumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):Crest Service Corp Address:12 Crest Drive City/State/Zip:Middleboro, MA 02346 Phone#:508.946.9800 Are you an employer?Check the appropriate box: Type of project(required): 1.D I am a employer with 6 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' = 9. 0 Building addition [No workers'comp.insurance comp.insurance. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.0 Other employees.[No workers' comp.insurance required.] *My applicant that checks box#l 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 him 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:The Hartford Policy#or Self-ins.Lie.#:08wecid7478 Expiration Date:7/212613 Job Site Address:16 Cozy Home Terrace City/State/Zip:W.Yarmouth, MA 0261 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 hereb certify lir he ¢i and penalties ofperjury that the information provided above is true and correct i atur-• rr%l� Date 5/8/2013 Phone#508.94•.9800 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#: • OYI� n CERTIFICATE OF LIABILITY INSURANCEDATE(MAVDD/Yrn) '4 3/5/2013 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(les)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(leu of such endorsement(s). PRODUCER CONTACT NAME: Select Dept ext 66807 Eastern Insurance Group LLC-Main PHONE Erm.508-651-7700 FM INC.xe)SOB-653 8089 233 West Central Street Natick MA 01760 Ao -selectwork g©easteminsurance corn INSURER(S)AFFORDING COVERAGE NAIL S INSURER A:Hartford Fire Inatranre Cn 19682 INSURED 15621 INSURER a:Hartford Insurance Co JC Bell Plumbing, Inc. INSURER C Twin City Fire Insurance Co 29459 Crest Service Corp. INSURER D: 12 Crest Drive Middleborough MA 02346 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2143206271 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. !NSA ADDL BURR POUCY EFF POLICY EXP LTR TYPE OF INSURANCE INCH MD POLICY NUMBER (MM/DD/YYYYI (MMND/YYYY) LIMITS A GENERAL LIABILITY OBSBAKL7984 /12012 5/12013 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITYDAMAGE TO RENTED -------------- PREMISES(Ea asanancel 5300,000 CLAIMS-MADE Ei OCCUR MED EXP(My one person) $10 000 - PERSONAL AADV INJURY $2,000,000 — _� GENERAL AGGREGATE $4,000,000 GENL AGGREGATEILRAMAPPPLIIES PER PRODUCTS-COMP/OP AGG $4,000,000 POLICY I^ 'PFQ I I LOC f B AUTOMOBILE LIABILITY OBUECZJ4031 12202012 12/20/2013 & NIN DroLE LIMI1 - 57.000.000 MY AUTO BODILY INJURY(Per person) S ALL OWNED X SCHEDULED BODILY INJURY(Paraccident AUTOS AUTOS ) f X HIRED AUTOS X NON-0WNED PROPERTY DAMAGE AUTOS (Per oxidant) S S A X UMBRELLALIAB X OCCUR 08SBAKL7984 6/12012 5/1/2013 EACH OCCURRENCE $4,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $4,000,000 DED X RETENTION$10,000 t $ C WORKERSCOMPENSATION 08WECID7478 7/2/2012 t/2/2013 X NO STATU- 10TH- AND EMPLOYERS*LIABILITY I TORY 1 IMITS I FR ANY PROPRIETORIPARTNERIEXECUTIVE Y N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatary In NH) EL DISEASE.EA EMPLOYEE 51,000,000 B yea describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $1,000,000 A Contractors Equipment 138SBAKL7984 6/12012 511/2013 Contractors Equip $10,000 ACV - owned,leased or Special Form rented by contact DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 161,Additional Remarks Schedule,a more apace Is required) Plumbing Contractor CERTIFICATE HOLDER CANCELLATION ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POUOY PROVISIONS. 1146 RT 28 South Yarmouth MA 02664 LIF ZED REPRESENTATIVE 1 t c,U t�-MLM[N 1 VVV ®1988-2010 ACORD CORPORATION. An rights reserved. ACORD 26(2010,05) The ACORD name and logo aro registered marks of ACORD - • • PLUMBERS ARC GASRTTERS -LICENSED AS A VASTER PLUMBER -q�\{{q- • : 'JEFFREY C BELL RRVV\• 12 CREST DRIVE • .MIDDLEBORO MA ::346-1857 11655 05/01/14 154810-�+ PLUMBERSWAND GASFM ERS T' LICENSED AS AA JOURNEYMAN PLU{N3-R JEFFREY C BELL � • 12 CREST DRIVE ~"tea MIDDLEBDRO MA 02346• -1857. • 20143 05/01/14 154811�� COVEMON:�!SAL':if 'J`rMASSl-C: US2iIS` : : Ito ti; S° i.-uE,a rtm •;. •�tUMBERS-A-ND-GAS-Flfii`E . REGISTERED AS A PLUMBING CORP • . . - ISSUES ABOVE uCMSETO:' EES .. • JEFFREY C BELL _ ^o: CREST SERVICES CORP • ` '. 12 CREST DR MIDDLEBORO MA •02346=1857.. • 3407 05/01/14 128363. \ ' --yII t 1 C2ri•cr� —_ .ITWi rola}__.__ 41 F0 JJ