HomeMy WebLinkAboutP-14-277 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ClTY,S Maut �__-___._j MA DATE tG'1�-! PERMIT RN' `a77
JOBSITE ADDRESS r 9U_ $l ted Ley G2 r/—1 OWNERS NAME 4.41 /rq /392:4_„471-224?)„,
P OWNER ADDRESS rya s rc'c)/ry yz cf I TEL SIB-39yes-7C,QFAX[ 1
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL G9
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[ ] PLANS SUBMITTED: YES❑ NO`XI
FD(TURESI FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE _ _ _
DEDICATED SPECIAL WASTE SYSTEM1 '
_
DEDICATED GAS/OIUSAND SYSTEM -
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM L
DEDICATED WATER RECYCLE SYSTEM .
DISHWASHER _
DRINKING FOUNTAIN .
F000 DISPOSER ' -
FLOOR I AREA DRAIN .
INTERCEPTOR(INTERIOR)
KITCHEN SINK _
LAVATORY l
ROOF DRAIN _
• SHOWER STALL �_ _
SERVICE I MOP SINK
TOILET , I
URINAL \, :v
WASHING MACHINE CONNECTION .
WATER HEATER ALL TYPES
WATER PIPING .
OTHER I445/icL I.2 /v_e t
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1 neT r)2 LQ13 t INSURANCE COVERAGE:
I have 2urrenf Iiabillty Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES>C NO
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! JQUGHECK�-P PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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--LimIUTY INSURANCE POLICY xj 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 vaive%this requirement
CHECK ONE ONLY: OWNER ;je AGENT ❑
SIGMTUTE OF OMER CRPWIT
I hereby certify that all of the details and information I have submitted or entered regarding this application are i : : • accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for lids applicafbn witl be h ..y .: with all P: ;-: . . . of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - �✓ /
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CITY 1/1 '`icL °f1Q/n___JSrATEI/7'. 1ZPLPa57, 1 -I277.97_a5.37J.yf�o
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Cs MMONWE4LTH OF MASSACHUEgTTS <_
DIVISION OF PROFESSIONAL LICENSURE-BOARD OF
P ' MBERS AND GASFITTERS- "
—.LICENSED AS A JOURNEYMAN PLUMBER.
�., ISSUES THE ABOVE LICENSE TO. '"e
JDHW A GRENDA
I. _- - a
21 SIESTA DR SrI!
t NAREHAM MAc0.2576 111
-- 307138 05/01/14 151609
LICENSE NO. EXPIRATION DATE - SERIAL NO. •
F•
•
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CONTROL# H359824
IMPORTANT
If this license is lost or destroyed, notify your Board at the: •
Division of Professional Licensure, 1000 Washington St,
Suite 710,Boston,MA 02118-6100.
If your name or address shown is changed, notify your boar4
of correct name or address to insure proper mailing of next
Renewal Application. Always refer to your license number. T
This license is subject to the provisions of the General Laws
as amended.It is a personal privilege,and must not be loaned
or assigned to any other person. Keep this license on your
person or posted as required by law.
AC?1 CERTIFICATE OF LIABILITY INSURANCE °"TE'""'DD1"Y)
8/12/13
THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIRCATE HOLDER THIS
CERTIFICATE DOES NOT AFFIIiAAA'TIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TIE COVERAGE AFFORDED BY THE POLICES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIRCATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the polies) must be endorsed. If SUBROGATION IS WMVED,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($.
IROCUCER CONTACT
NAME:
Legacy Insurance Agency Group, PHONE/C Nd: (508) 295-6730
213 Main Street AAA=
(508) 295-1315
AODRI= maria.almeidaelemacyinsurancegroup.com
Wareham, MA 02571 - INSURER(S)AFFORDIN3 COVERAGE NAICA
. INSURER A:Western World
NSLRED INSURER B:
John A Crenda IIauRERc:
21 Siesta Dr • INSURER D: -
West Wareham, MA 02576 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSIRED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTVVITHSTANDNG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTFICATE MAY BE ISSUED OR MAY PERTAN.THE INSURANCE AFFORDED BY TIE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL 1HE TERMS,
EXCLUSIONS ANDCONDITIONS OF SUO-IPOUCIES.LMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
XI TYPE OF INSURANCE MIEIR
NSR MID POliCY MJRWERPOLICY CY IDCP
IMMNDIYEYYY) TAIM/FF DLYYYYY) UMTS —
A GEN14PP8183660 7/29/13 7/29/14 EACH OCCURRENCE $ 1.000.000
RENTED
X COMMERCIAL GENERAL LIABILITY PRFMISESGEO(Ea accunencal $ 100.000
CIAMSMADE ®OCCUR MED OP NM one pram) $ 5.000
PERSONAL a ADV INJURY $ 1.000.000
GENERAL AGGREGATE $ 2.000.000
'G�E�N'LAGGRE(�1GATELMAP
TPLES PER - - PRODUCTS-COMPIOPAGG $ 1.000.000
I
1 POLICY 1 SCT r LOC $
• DSINGLELMU S
AUTOMOBILE LIABILITY C Ea )
ANY AUTO BODLY INJURY(Pr Temon) $
ALL OWIED SCHEDULED BODILY INJURY(Per now* S
AUTOS NON-OWNEDNOPpRROPRT
EY DAMAGE $
_HIRED AUTOS' _AUTOS , Pracdtlenll
$
UWRELLA LIABOCCUR EACH OCCURRENCE $
EXCESSUAa I CLAIMS-$MI AGGREGATE $ -
DED RETENTIONS $
• NORICUM COMPENSATION WC STATU- ' 0TH-
INDEMPLOYERS'LNeIUTY YIN TORY Nag FR
ANY PROPREIOiWAR11W)I OJTAEN/A - EL.EACH ACO CEM $
OFFCRMEII CREXCLWEDT
Siandabry in NH) EL.DISEASE-EA EMPLOYEE $
r d untler
DESCRIPTIONthbe U OPERATIONS below EL.DISEASE-POLICY LIMIT $
•
CESCRIPI1ON OP OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Atldeond RerarS Schedule,II more'Pa Stem/r n
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF NE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
TIE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED N
ACCORDANCE WITH THE POLICY PROVISIONS.
A REPRESENTATNE •
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Annan ss I91H n/nc1 The ACORD rams and Man am Faceted mat of ACORD