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Home My WebLink AboutBLDG-23-004392 #5— ', . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH MA DATE February 08,2023 PERMIT# BLDP-23-004392 tL- kr,, JOBSITE ADDRESS 15&7 CORDICK RD OWNER'S NAME VALLE JOSEPH R G OWNER ADDRESS VALLE EILEEN L 5 CORDICK RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR . GRILLE _INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 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 ❑ NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND El 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-GASFITTER NAME (Michael Mcbride LICENSE# 119681 SIGNATURE MP❑ MGF ❑ JP© JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: IMICHAEL R MCBRIDE I ADDRESS. 9 Rustic Drive, CITY IWest Yarmouth I STATE MA ZIP 102673 I TEL I FAX I I CELL 1 I EMAIL Istinger.mcbridenai mail.com I SACHUSI 1 i S UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY E .E r o v l w l MA DATE PERMIT II 2 3 -- 43 2 —2---k/Z---- B 1.)4 c9B�.,,,•^3DD E CQrj /G v�—CJ 1/(. - OWNERS vl / e By . NG ES (Lil 7 TEL ` 7 / FAX ENT TYPE OR E . COMMERCIAL❑ EDUCATIONAL D RESIDENTIAL 1A. PRINT CLEARLY NEW:Q RENOVATION:0 _REPLACEMENT:0 PLANS SUBMITTED: YES45. NO( , FIXTURES 1 FLOOR-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 F BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM - DEDICATED WATER RECYCLE SYSTEIv1 DISHWASHER ' DRINKING FOUNTAIN FOOD DISPOSER -FLOOR I AREA DRAIN INTERCEP 1 OR(INTERIOR) KITCHEN SINK - LAVATORY ROOF DRAIN SHOWER STALL SERVICE!MOP SINK TOILET URINAL WASHING MACHINE CONNECTION / WATER(-IEA 1 tR ALL TYPES / -, WATER PIPING OTHER ESTIMATED VALUE OF WORK: I I t I I I I I I I I I I I I + INSURANCE COVERAGE: - I haves current liability insurance policy or its substantial equivalent which meets the requirements of P IGL Ch.142. YES a NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY VA OTHERTYPE 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 - CHECK ONE ONLY: OWNER E AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information 1 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 1/all Pertinent provision of the, Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws �� / n `,/�f PLUMBERS NAM "r E I �J C=I P LICENSE c 1 1 ��/ SIGNATURE MP 0 JP 04. CORPORATION Q# P c -Q 2 PARTNERSHIP 0 LLC{ 1# NP` - ADDRESS . 7 J 'r- ii i'-II dI 1T0z-pCOMPANY NAME � C� �► �-P � �/I CITY V GI A/‘t 5 STATE('# ZIP O 7, O/ TEL 7 7 11 YID 4 I Z Z FAX CELL EMAIL T-1/t 5 8,--` M c13 r i 7 lu-441-'6241 • The Commonwealth of Massachusetts ; . -� �� / Department of Industrial Accidents .. 1 Congress Street,Suite 100 e! Boston,MA 0217¢2017 • • .ww .massgov/dia Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibiy Name(Bnsiness/Orgauization/Individual): Address: • City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.1:1 I am a employer With employees(full and/orpart-time).* 7. ❑New construction 20 I am a sole proprietor orpartnership and have no employees working forme is . any capacity.[No workers'comp.insurance required.] 8. Q Remodeling 3.QI am a homeowner doing all work myself.[No workers' rnsmance t g• Q Demolition • . comp.� �1�.3 4.1:1 I am a bomeowner and will be kiting contractors to conduct all work on my property_ I will10 Q Building addition ensure that all contractors either have workers'compensation insuranm orate sole 1 LQ Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 50 Isola general contractor and I havehirzd the sob-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.I 13.QRoof repairs ' 6.0 We area corporation and its officers have exeicised their right of exemption pea MGL c. 14.D Other 152,01(4),and we have no employees.[No workers'comp.insmancc required *luny applicant that checks box it 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 colors most submit a new affidavit indicating such. tConhactors that.tvckthis box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-contractors have employees,they most 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: Policy#or Self-in&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 fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fora 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 of perjury that the information 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): 1,Board of Health 2.BuldiiigDepartment 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ' 6.Other Contact Person: Phone#: