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HomeMy WebLinkAboutBLDP-23-006084 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 5/4/23 PERMIT# BLDP-23-006084 I I' 9 JOBSITE ADDRESS 8 AMY LN OWNERS NAME TRUGLIO KRISTEN L OWNER ADDRESS 19 WINCHESTER ST#811 BROOKLINE,MA 02446 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES El NO❑ FIXTURES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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 WATER PIPING 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❑ 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. 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 (John Kane I LICENS4242755 I SIGNATURE MP ❑ JP © CORPORATION ❑# I I PARTNERSHIP ❑# LLC ❑# COMPANY NAME IJOHN KANE I ADDRESS 139 MONOMOY RD CITY IS YARMOUTH I STATE IMA I ZIP 1026641984 I TEL I I FAX I CELL I I EMAIL Ijkanee45@yahoo.com m P /3/9 ri c / MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK UM- _:.I.I_ CITY a Il MO U f� arf MA DATE IT/tA y i a3 PERM' 11_ (7 JOBSITE ADDRESS g 4m>� 1-a IncOWNER'S NAME 1 Wt' E b�/E Is OWNER ADDRESS So 141 e ' TEL SOFA a G a -6 3' 6 FA Y p 4 2023 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENT' L PRINT BUILDING DEPARTMEN CLEARLY NEW:❑ RENOVATION:.1( REPLACEMENT:❑ PLANS S FIXTURES 7 FLOOR-+ 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 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 ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ij' NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ei3 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 co fiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# aa2 7�SS ( SIGNATURE MP❑ JP® CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Jack Ka Inc /fa n 1-r a c 1-/n y ADDRESS 3 9 in d h d art/ ( I CITY S STATE .VYI F ZIP 4 r3 6 6 V TEL FAX CELL Sd$^ '6s`C EMAIL 3 Kant.< 45-8 yet ko0 coVh • • The Commonwealth of MaSsachusetts _-if_ /. Department of IndustrlalAccidents • _i:1�► ' • 1 Congress Street,Suite 100 • Boston,MA 02114-2017 • • www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Pliimbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/lndividual): . Address: - . • City/State/Zip:. Phone#: Are you an employer?Check the appropriate box: Type of project(required): i.Q I am a employer with employees(full and/or part-time).* 7. ❑NeW construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling • any capacity.[No workers'comp.insurance required.] • 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition • 4. i am a homeowner and will be hiringcontractors to conduct alI work on myl 0❑Building addition ❑ property. I will ensure that all.contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions s.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.igsurance.t 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per M_CL a 14.❑Other • 152,§1(4),and we have no employees.[No workers'comp.•insurance required.] *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 am doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached kn 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. Jam an employer that is provla7ng workers'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(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 fins 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 certify under the pains and penalties ofperjury that ihiinformation provided above is true and correct. Signature: Date: • 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): . I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector • 6.Other • Contact Person: Phone#: