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Home My WebLink AboutBLDP-16-003705 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK —_^'v c/j'_ c CITY I . ` it t2mOc MA DATE /a I$I/5 u/9l4-/fir aG`PERMIT# ITN, JOBSITE ADDRESS Li fl1d €E 5 ) I OWNER'S NAME C I- iZ i3 �OLay POWNER ADDRESS 60 1-0 00A I D f• P C.& O e I TEL1781-7FS9—805 I IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NOM FIXTURES 1 FLOOR-, 1 5 8 10 14 BATHTUB i CROSS CONNECTION DEVICE I'' DEDICATED SPECIAL WASTE SYSTEM °'' DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN UR•R R 11111111 II IC U FOOD DISPOSER UM =II FLOOR I AREA DRAIN 111111__Ell EMI NO IN VIII'11111111111P MIIIII 1111111.Pm MIN M, INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 1ill ROOF DRAIN SHOWER STALL I SERVICE I MOP SINK TOILET I URINAL , - WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING it OTHER t i)i V Pit_V>✓ 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 El 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 pilance Pertinent,provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME[Chris Briggs 'LICENSE# 12901 I SIGNAT RE MP❑ JP❑ CORPORATION[]#[323B !PARTNERSHIP❑# I LLC❑# I COMPANY NAME Briggs&Heino Plumbing&Heating Co.,Inc I ADDRESS P.O.Box 538 CITY Centerville (STATE MA I ZIP P02632 ( TEL 508-778-0816 FAX 508-775-0404 CELL EMAIL rbrihi@aol.com i ROUGH PLUMBING INSPECTION NOTES BELOW FOR I:IFFICE USE ONLY FINAL INSPECTION NOTES Yes No /2b4Z & Ok /Qh THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# i i PLAN RE1VIEW NOTES -I I I ,I 1 -1 -I -1 * The Commonwealth of Massachusetts !1 1, Department of Industrial Accidents =;;jeii= 1 Congress Street, Suite 100 ,Y=_ : Boston, MA 02114-2017 — v' www.mass.gov/dia mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/individual):Briggs& Heino Plumbing & Heating Co., Inc. Address:P.O. Box 538 City/State/Zip:Centerville, MA 02632 Phone#:508-778-0816 Are you an employer?Check the appropriate box: Type of project(required): LEI I am a employer with 3 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.1:1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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:The Hartford Policy#or Self-ins. Lic. #:08WECRJ6614 Expiration Date:02/22/2016 Job Site Address: ''1 V ineCEE , City/State/Zip: It). '/4/e.,r?, rho v )/7 j Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c fy under the pains and enalties of perjury that the information provided above is true and correct Signature: a 0 . r' Date: /a/s 115 Phone#: 508-778-0816 I 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#: