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Home My WebLink AboutP-13-714 - .C ., MASSACHUSETTS UNIFORM APPLICATION FQR A PERMIT TO PERFORM PLUMBING WORK li . i7_/ 731;_ /a1�9 i ;^__r(II�y CITY �, yea-ft-Wilt MA DATE PERMIT# v�( ✓'� JOBSITEADDRESS c( ( 00/10h .Jf. OWNER'S NAME C;fi y 6c,j)kSt' i P OWNER ADDRESS - S4'+1 t / TEL 72y-,,y-77/9' FAX — TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 _ . RESIDENTIAL 0 PRINT. . CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑ FIXTURES 7 FLOOR-. _ BSM 1 2 3 4 5 - 6 -7 8 9 10 11 12 13 14 BATHTUB I r i' r r CROSS CONNECTION DEVICE I i DEDICATED SPECIAL WASTE SYSTEM DEDICATEGAS/OIL/SANDSYSTEM 1 �'[ �� [ �� D - 1 r n DEDICATED GREASE SYSTEM l -.. DEDICATED GRAY WATER SYSTEM I i II - I. I ' 'I II 1 r DE CATED DRINKING DISHWASHER ARNECYCLESYSTEM 1 ',� r , I' '� I.,.... ia�" FOOD DISPOSER I 1 ,5 r FLOOR/AREA DRAIN a SIM INTERCEPTOR(INTERIOR) KITCHEN SINK =S � �� # LAVATORY ROOF DRAIN ati SHOWER STALL SERVICE/MOP SINK iIiiiIiiIiiiiiI TL WASHING MACHINE CONNECTION 5_a me. sass 5 III San WATER PIPING i I1.111.1111 ' 1112111 ,I , . r I '�' I r , l I. I 1 r T. INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q 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 D 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 ❑ 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 ca lance w••V1 all Ppppggqinentprovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , � Y . e d PLUMBER'S NAME Bradford Piesco ILICENSE# 10512 1 CV// seed PLUMBER'S SIGNATURE MPD JP CORPORATION Q# 3479-C PARTNERSHIP❑# LLC❑# COMPANY NAME Nurotoco of MA d.b.a Roto-Rooter ADDRESS 175 Maple Street CITY Stoughton STATE MA ZIP 02072 TEL 781-297-7049 FAX 781-341-8817 CELL 774-259-2439 EMAIL Bradford.Piesco@rrsc.com I I I1 lr; Ili !e, 11 1 i 14 III In nil • 2 l . '-1[1 A R 23 0IL1c a & isUuiuL. r:PT • Cy_ _A .--- ACC0R0 CERTIFICATE OF LIABILITY. INSURANCE DoTE(MMOOMYY ) 5/23 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 lieu of such endorsement(s). • PRODUCER CONTACT MARSH USA INC. NAME; 525 VINE STREET,SUITE 1600 ((NCC PHONNo EMI: (/C.No): CINCINNATI,OH 45202 - EMAIL Aim:Ci(XAman.CeftrequBSt@marSII.COM ADDRESS: INSURER(S)AFFORDING COVERAGE • NAIC I 400408-RR5C-GAUW13-14 00015 • INSURER A:Old Republic Insurance Co 24147 INSURED INSURER B:National Union Fife Ins Co Plasblrgh PA 19445 15-ROTO-ROOTER SERVICES COMPANY 175 MAPLE STREET INSURER C: . STOUGHTON,MA 02072 INSURER D: • INSURERE: INSURERF: COVERAGES CERTIFICATE NUMBER: CLE-003527060.13 REVISION NUMBER:3 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.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR INSR WYD POLICY NUMBER (LIWDORYYYI (MWDD/YYYY) LIMITS A GENERAL LIABILITY MWZY60132 - 04/01/2013 04/012014 EACH OCCURRENCE $ 2,000.000 GE TO RENTED X COMMERCIAL GENERAL LIABILITY ' PREMIISES(Eaocrunencel $ 750,000 CLAIMS-MADE []OCCUR - MED EXP(My one person) $ 5,000 PERSONAL&ADV INJURY _ $ 2,000,000 • GENERAL AGGREGATE _ $ 6,000,000 GLEN.AGGREGATE LIMIT APPLIES PER PRODUCTS•COMP/OP AGG $ 6,000.000 —X1 POLICY n PEP n LOC $ A AUTOMOBILE LIABILITY MWTB21957 04/01/2013 04/01/2014 COMBINED SINGLE LIMIT 5,000000 (Ea accident) § _ X ANY AUTO • BODILY INJURY(Pe!person) $ AUTOS OWNED AUTOESDULED BODILY INJURY(Per accident) S X X NON-OWNED PROPERTY DAMAGE _ HIRED AUTOS _ AUTOS (Per accident) $ $ B X UMBRELLA LIAR X OCCUR 20562053 04101/2013 04/01/2014 EACH OCCURRENCE $ 5.000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5.000,000 _ DED X RETENTION$25'°00 $ A WORKERS COMPENSATION MWC11826400 04/01/2013 04/01/2014 X WCSTATU• 01-H- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS FR ANY PROPRIETORNTARTNERIEXECUTIVE El EACH ACCIDENT $ 1,000'000 OFFICEFVMEMBER EXCLUDED? N/A (Mandatory In NH) - E.L.DISEASE-EA EMPLOYEE $ 1.000.000 B RIPTIONunder DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ 1•000'000 • DESCRIPTOR OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more pan Is required) EVIDENCE OF COVERAGE. ' • CERTIFICATE HOLDER CANCELLATION • ROTO-ROOTER SERVICES CO. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 175 MAPLE STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN STOUGHTON,MA 02072-1130 / ACCORDANCE WITH THE POUCY PROVISIONS. • AUTHORIZED REPRESENTATIVE of Marsh USA inc. I John F.Schultz ' d't.,---`5'-1 t ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) - The ACORD name and logo are registered marks of ACORD e' - - - - ...-• ,�2 • Department of Industrial Accidents • �- I. Q. ,9Ofce of Investigations 1 Congress Street,Suite 100 t `__ a Boston,MA 02114-2017 y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information t • Please Print Legibly Name(Business/Organization/Individual):Nurotoco of MA d.b.a. Roto-Rooter Services Address:175 Maple.Street City/State/Zip: Stoughton MA. 02072 Phone#: 761-297-7049 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 70 4. ❑ I am a general contractor and I have hired the sub-contractors 6. 0 New construction employees(full and/or part-time).* . listed on the attached sheet. 7. 0 Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g- 0 Demolition working for me in any capacity. employees and have workers' comp.insurance? 9. ❑Building addition [No workers'comp.insurance required.] 5. ❑ We area 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.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.0 Other employees. [No workers' comp.insurance required.] 'Any 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 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: Marsh USA . Policy#or Self-ins.Lic.#:WC-9379366-07 Expiration Date: 4-1-2014 Job Site Address: City/State/Zip: 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 cert• nder I e pains and penalties offerjury that the information provided'above�is true and correct Siznature: � Datef Phone#: 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#: ,