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Home My WebLink AboutP-14-041 (17 Simpson Avenue) 4 �t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK •=c" a;.lifi Q CITY Yarmouth MA DATE 7/9/2013 PERMIT# p//' S JOBSITE ADDRESS 17 Simpson Ave OWNERS NAME Katie Rouse P OWNER ADDRESS TEL 973.326.9534 FAX 508.946.5650 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES❑ NO0 FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 I 13 14 BATHTUB I P I , r CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM i. Vii. i �, DEDICATED GAS/OILISAND SYSTEM �, DEDICATED GREASE SYSTEM r DEDICATED GRAY WATER SYSTEM I ` ( I' I I DEDICATED WATER RECYCLE SYSTEM J I DISHWASHERA DRINKING FOUNTAIN 1 I I .I � i I FOOD DISPOSER I 1 I - FLOOR/AREA DRAIN II f G`, E I �� - i INTERCEPTOR(INTERIOR) I I 1 h. KITCHEN SINK � i I r n c y 1 I LAVATORY �. Y I - I ROOF DRAIN )I SHOWER STALL 1 , BCrr i1 SERVICE/MOPSINK TOILET1 ISN i URINAL ' WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _ I WATER PIPING j, I r' OTHER r i. 1- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO a IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY 0 OTHER TYPE OF INDEMNITY 0 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 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- AV:to •e best of in .• edge and that all plumbing work and installations performed under the permit Issued for this application will be in com.,r' h al : •nent. • .ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , PLUMBERS NAME Jeffrey Bell LICENSE# 11655 SIGNATURE MPO JP El CORPORATION E# 3407 1PARTNERSHIP❑# LLCEI# COMPANY NAME Crest Service Corp - ADDRESS 12 Crest Drive CITY Middleboro STATE MA ZIP 02346 1 TEL 508.946.9800 1 FAX 508.946.5650 CELL 781.249.9529 EMAIL mrrootersma@gmail.com /v The Commonwealth of Massachusetts • = Department of Industrial Accidents f.6=irr=. i Office of Investigations =3?Illi- 1 Congress Street,Suite 100 Boston,MA 02114-2017 '4•s'1%0 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers 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): 1.0 I am a employer with 6 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 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 g, 0 Demolition workingfor me in anycapacity. employees and have workers' P tY• t 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 q ] officers have exercised their 1 1. Plumbingrepairs or additions 3.❑ I am a homeowner doing all work ❑ P myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fdl 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:The Hartford Policy#or Self-ins.Lic.#:08wecid7478 Expiration Date:7/2/2014 Job Site Address: 17 Simpson Ave City/State/Zip:W.Yarmouth, MA 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 D urance coverage verification. I do hereby certify u r r r end penalties o perjury that the information provided above is true and correct. 7/9/2013 Sienature: Da e: phone#: 508.9469800 Official use only. Do not write ha 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#: PLUMBERS AAV GASFITTERS LICENSED AS A VASTER PLUMBER . •JEFFREY C BELL Vt. ti' '-12 CREST DRIVE • 8 .MIDDLEBORD MA :.'346-1857 11655 05/01/14 154810 PLUMBERS AND LICENSED AS_A JOi3RNEYMANGASFITTERS PLUMSnc_ • JEFFREY C BELL r;J` li- 12 CREST DRIVE ," '' MIDDLEBORO MA ; 20143 05/01/14 • :154811 11:14'415:0,0 . . tit I rc 1':.t" li i ;islItti, PL 1N/BERS„ —Ai11D—GASFITTCRS—' — • REGISTERED AS A PLUMBING CORP, ti. ISSUES 7145;Srnfa L.1CZ.SZ1O:- • -�•�... JEFFREY C BELL -: ` 5, -CREST SERVICES CORP �� 12' CREST DR ,....no �;s� MIDDLEBORO MA -02346=1857=185 •\� 3407 05/01/14 128363. \ ' ♦! rti5 N -- i 7t?5;t�z 47— 2.5.7-.1 . At ve CERTIFICATE OF LIABILITY INSURANCE7,9,2013°""""") 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(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 NAME: Select Dept ext 66807 Eastern Insurance Group LLC-Main inc.*Exte50&651-7700 FAX N*508 653 6089 233 West Central Street E-MAIL Natick MA 01760 AoDREssselectwOrk({@easteminsuranfe corn INSURER(S)AFFORDING COVERAGE NAIC INSURER A:Hartford Fire Insurance Co 19682 INSURED 15621 INSURER B:Hartford Insurance Co JC Bell Plumbing, Inc. INSURERc:Twin City Fire Insurance Co X9459 &Crest Service Corp. INSURERD: 12 Crest Drive Middleborough MA 02346 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1413983999 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 TYPE OF INSURANCE ADDL SUBR POLICY EFP POLICY EXP UNITS LIRINSR WVD POLICY NUMBER (MMIDD/YYTY) IMM'DDIYYYYL A GENERAL LABILITY 085BAKL7984 6/12013 5/1/2014 EACH OCCURRENCE $2,000,000 AGE TO D X COMMERCIAL GENERAL LIABILITY PPREMSES(Eaocc nonce) $300000 CLAIMS-MADE n OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE WAIT APPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000 n POLICY I^ F P LOC $ B AUTOMOBILEUABILJTY 08UECZJ4031 12/20/2012 12/20/2013 (EjMWNSJbINI,LELIMII $1000000 ANY AUTO BODILY INJURY(Per person) $ AUTOS ED X SCHEDULED l AUTOS BODILY INJURY(Perawdent) $ NON-0NMED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per acdden0 $ A X UMBRELLA UAB X OCCUR 08SBAKL7984 6/1/2013 &12014 EACH OCCURRENCE $4,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE $4,000,000 DED X RETENTION110,000 $ C WORKERS COMPENSATION 08WECID7478 7/2/2013 7/2/2014 X WC STATU- 0TH- AND EMPLOYERS'LIABILITY YIN TORY DMITS FR ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? V❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 II yyes desalbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMO' $1,000,000 A Contractors Equipment 08SBAKL7984 5/12013 - 3/1/2014 Contractors Equip 510,000 ACV owned,leased or Special Form rented by contact DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,I mon space 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 POLICY PROVISIONS. 1146 RT 28 South Yarmouth MA 02664 AUTHORIZED REPRESENTATIVE 0 ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD