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HomeMy WebLinkAboutBLDP-21-004234 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w, CITY YARMOUTH MA DATE 1/29/21 PERMIT# BLDP-21-004234 at - p JOBSITE ADDRESS 39 ALDEN RD OWNER'S NAME MORRIS LAWRENCE P OWNER ADDRESS MORRIS BARBARA M 33 BURBANK RD SUTTON,MA 01590-2429 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES 1 FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING 1 OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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. 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Richard Leveillee LICENSE 26263 SIGNATURE MP 0 JP © CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME Richard H Leveillee I ADDRESS 87 BURNCOAT ST CITY WORCESTER STATE MA ZIP 016051334 TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT 0 ❑ FEES$ PERMIT# PLAN REVIEW NOTES l-' f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,. c, EI CITY I 4,4I r l#i MA DATE I f Th Oji' PERMIT# Li,'-moi _,40 ♦3/ JOBSITE ADDRESS i. A C—1 4J) I OWNER'S NAME _ __ _-__ _I P OWNER ADDRESS / 0Zi`i11m ,W', TEL FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL ; PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:)`<, PLANS SUBMITTED: YES 0 NOD FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 1 8 9 10 11 12 13 14 BATHTUB Ill INK IIIIIIIII.VIII ' 'll II I iI 1I I 'I - CROSS CONNECTION DEVICE I .Ij�=1.1111.1111.11111111.11111.11jaillia. l� DEDICATED SPECIAL WASTE SYSTEM ,`) I�,iMM.= DEDICATED GAS/OIL/SAND SYSTEM M '1( =I: ' ' ' . DEDICATED GREASE SYSTEM Ii, 1 I I !I ! I I 'I I DEDICATED GRAY WATER SYSTEM ;—;'am Ri =—=';..."I Il—:L ill DEDICATED WATER RECYCLE SYSTEM Imo: ':,IM ION OMNI IN—!,NM NOM INN I DISHWASHER I 1 ) IN'N'1 � I�` MIMI DRINKING FOUNTAIN Imo_ ,m 'I 1 1l UNi li FOOD DISPOSER NW Imo'_'1 ;_'_1 OM Mt I I Mar l!,N FLOOR I AREA DRAIN i Imo!Pm 11 1 .I OM MO I �l��t�:i+i��t iall,na:�.•.:�I um en,NM OM illi .11111111111111.111.11.ll l l KITCHEN SINK nom!> =OM 111111111111111 Imo:N MIK MS ll (111 LAVATORY N'N''MI'.l ll am a'a mist-Will. it ROOF DRAIN 11111111 INV NM li IIIIIIM MK an ma ; SHOWER STALL i Imo` Jr.:I 'll := »I :' .I SERVICE!MOP SINK . ;) :' , I .�IIS 1a NMNMI MI IIIA;Imo; i TOILET I I IIID ' I' Imo IIID I an URINAL II;Imo!MIMI11111111Mir JIM IIIIM INIII IM 'SWIM 1111 III 'i NM I WASHING MACHINE CONNECTION =INS;111 NU1 IM 1l ;mil IIIA;am I> !11 ams WATER HEATER ALL TYPES �. NMI 1111111 NW;NM NMI IS NEI, Imo,IM 1 Its MIS WATER PIPING I ; ;I IIS I .'1111111011111111—1N 101111.*Nig ----- -- - - -- — - --- OTHER IIS f .lll ;>II ,) .^Ii 'LI imaimmaimi .—IIIIII• '1I -__111°__11111111:__ '-- 111 1 lam;11.1.11111111111111.11.1111111.111111101.1.1alli,=mit lrill.'I alit ;1 MI 1111111.11 _1 N II INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MG CiYESat,—... S10'} - r IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYOTHER TYPE OF INDEMNITY El BOND 0 JAN �l t I OWNER'S INSURANCE WAIVER:lam aware that the licensee does not have the insurance coverage requi - . &Chi0tbll(142%fel-M_r• Massachusetts General Laws,and that my signature on this permit application waives this requirement. By .tea. 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 applicatibeon are true and accurate to the best of m knowledge and that all plumbing work and installations performed under the permit issued for this application win in compliance with all t pro ' ' n of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / I Ric/I'LL! PLUMBER'S NAME .. p4" / 4/f, LG (CENSE#ia-4.:1,4.. l 1 SI iNATURE MPD JP CORPORATION 0#j ;PARTNERSHIP#Er LLC 0#, I COMPANY NAME' ADDRESS --"v,:yst-:% 5 j CITYIi ,:l.S.-- ./%' , _ I STATE ZiP 0 0/405�'7I TEL SL?tF"- -3`I'D (;` FAX .. -..,_-----I CELL EMAIL _ Itle ti _ i.v::/ v _ 4 r TOWN OF SUTTON 4 UXBRIDGE ROAD SUTTON, MA 01590 PH:(508)865-8723 FAX: (508) 865-8721 Plumbing Permit Fee Schedule ALL INSPECTIONS MUST BE SCHEDULED THROUGH THE BUILDING DEPARTMENT RESIDENTIAL FEES One and Two Family,---------------------------------_ —___�___------$50.00+$8.00 per Fixture—Per Unit Additions,and Renovations SingleFixture ------------------------------------------------ -------$45.00 Code Violations/Re-Inspection Fee/Additional Inspections------------------$45.00 Gas Hot Water Heater(Requires paperwork for both Plbg and Gas) ---$48.00 PlanReview---------_—_-----------------------------_---_—__----_---__---__---$50.00 COMMERCIAL/INDUSTRIAL FEES Commercial/Industrial(Includes up to 3 inspections)------------------$100.00+$10.00 per Fixture—Per Unit Additional Inspections-- -------- -$45.00(Paid at time of application) Single Fixture--------------------------------------$50.00 Code Violations/Re-Inspections-------_,____________________��_ $4500(Paid prior to inspection) PlanReviews---------------------------------------------------------_ $50.00 Please note the following: ❖ No person shall construct,add to or alter any portion of the plumbing(except to make a repair)until a permit has been filed and all fees are paid. ❖ Work started without a permit is subject to double the Fee Schedule. ❖ Permits can be issued only to persons or businesses holding a valid MA Plumbing,Gasfitting or LP Installer License. ❖ Outdoor Sprinkler Systems must have a Back-Flo Proventor installed by a Licensed Plumber. ❖ All Filter Systems require installation by Licensed Plumbers r The Commonwealth of Massaehmetts Pin_'- 1, Department of Industrial Accidents „ter- 1 Congress Street,Suite 100 `..:-,,S.17-1:4--. y Boston,MA 02214-2917 www.mass.gov/tlia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PER1WII'I"PING AUTHORITY. F ApplicantInformation Please Print Legibly '-) / L/ Name(Business/Organization/Individual):: )'i rfr.�m4 -! . 77 L�._.-. =./ci..,".. •t Address: / ;; t7 '17 5/. City/State/Zip: ‘t. Jc Si 5714%/, . <',Ct Phone#: J-(1-<( r- . Are you all employer?Check the appropriate bog: Type of project(required): 1.0 t am a employerwith ... employees(fall and/or part-time).* 7. 0 New Construction .• • 2.t I am a sole proptietororpartnership and have no employees welling.forme in s. I]Remodeling • • any capacity.[No workers'comp.insurance required.] 9. ❑Demolition • .30 1 am a homeowner doing all workmysclf.[No workers'comp.insurance remitted.]t 10 0 Building addition 4.0 I am ahontcowner and mill be hiring contractors to conclude!'work on my property. I Will i ensure that all contractors either have workers'compensation insurance 11.0 Electricalairs or are sole .rep or'additions proprietors with no emtsloyees. 12.aPlumbing repairs or additions 5.0 I am a general contractor and I:bave hired the sub-contractors listed on the attached sheet. 13.1:Roof repairs These sub-contractors have employees and have workers'comp.insurance? 14.0_Oiher 6.❑War e e a oat-potation audits entersbave exercised their right of exemption per MGL c. •152,§l(4),andwc have-no employees.[No workers'camp.insurance required I *Any applicant that checks box#I 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. 1Coateractors that check this box Must attached an additional sheet showing the name of the sub-coatinetors and state whether or not thoseuntitica have employees. if the sub.contractors have employees,they myst provide their workers'comp.•policynumbcr. I am an employer that is providingworkere compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: . Policy#or Self-ins.Lic.#:- _ Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation.policy declaration page(shoOing 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 imprisonriient,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 ofthe DIA for insurance coverage verification. I do hereby eartrfy un er to ains and en ties ofperjury that the information provided above is true and correct 7� �/ Date: /—Z7--- .,\ / Signature: l i/ !/ Phone#: 7-Th . j 11,0 _ /".7‘',.-Z 3 / . 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.CitylToWn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: e , . From: morriselectric33@aol.com Subject: License Date: Jan 10, 2021 at 6:43:55PM - To: mornselectnc33@gmail.com Shared via the AOL App. ... ,., • ,•'••;,'A•,,•;<1•4!••2•'„'"T*1„.1••;4r,#!'", ,,'S,Vilittigt4t,, ,,,i'4,!!!,,, '4 !• : s•,,t„,.., • A'; ''‘''''4;,:,•.>,'''•..-;*:'?IttIV.A.14. 1 i'''Z'''Tf,%.''''''''''''''*''`• ''' • .. < '''''.444L'4'.''''''',•„,'LL'...r.••••#,'•*4'' .< ...., < ' .• , < • , •,' l'4%."•:If•Nf•^'4,•,',•'''"''<tlef,''•• 'n7..":•.,.•9 ,• ..- ' '-. •••- .: ',,,„-,,,, ___,.,--t•.:,1,*,„,- -•::::',4 •,_•,.. s„ . , . , ...... „,,,,•....,,,k,........«...., t",", ''''.:;'r>-,„•fP:',.•--;•7••n'•-•*,•,r4.;.z,,,,,:--,',....:`4,:ot "f:-••••,-, , • •••• .. 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