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HomeMy WebLinkAboutBLDP-21-001153 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK C7. CITY YARMOUTH MA DATE 9/3/20 PERMIT# BLDP-21-001153 JOBSITE ADDRESS 47 SISTERS CIR OWNER'S NAME ROBERTSON DOUGLAS A TRS P OWNER ADDRESS RYER JANE E TRS 868 WATERTOWN ST W NEWTON,MA 02465 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 3 3 ROOF DRAIN SHOWER STALL 1 1 SERVICE/MOP SINK 1 TOILET 2 2 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER 1 WATER PIPING 1 1 OTHER 4 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ 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 ANDREW LEVESQUE LICENSE 1162 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME HARWICHPORT HEATING AND ADDRESS 461 LOWER COUNTY ROAD COOLING CITY HARWICHPORT STATE MA ZIP 02646 TEL FAX CELL EMAIL andy@hphcllc.com 4 I , i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t _v -'`"= YARMOUTH PORT _,t(_s CITY/TOWN MA DATE 8/27/20 PERMIT# ZI"�I( JOBSITEADDRESS 47 SISTER CIRCLE OWNER'S NAME BASSIL P ' OWNER ADDRESS TEL 774-487-0807 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El PRINT CLEARLY NEW:(A RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO D FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUBt CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GAS/OIUSAND SYSTEM • _DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM i; DEDICATED WATER RECYCLE SYSTEM DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 3 3 ROOF DRAIN SHOWER STALL 1 1 • ' SERVICE!MOP SINK 1 TOILET 2 2 _ URINAL WASHING MACHINE CONNECTION 1 • WATER HEATER ALL TYPES 1 WATER PIPING •OUTDOOR SHOVVER OTHER 1_ 1 4 SILLCOCKS INSURANCE GE I have a current liability insurance policy or Its substantial equivalent V w which is the requirements of MGL,Ch,142 YES IVNO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE Box BELOW ❑ LIABILITY INSURANCE POLICY ! ' OTHER TYPE 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY; OWNER ❑ AGENT ❑ I hereby certify that all of the details and Information I have submitted or entered regarding this application are taste and accurate to the best of my knowledge and that all plumbing work end 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. t PLUMBER-GASFITTER NAME Andrew Levesque LICENSE# 7�� �. �� g PL15162 GNATU MP Nj MGF❑ JP d JGF❑ LPGI❑ CORPORATION D# PARTNERSHIP❑# LLC Ri# 3944 COMPANY NAME Harwich Port Heating&Cooling LLC ADDREss 461 Lower County Rd cry Harwich•Port STATE MA ZIP 02646 TEL 508-432-3959 FAX 508-432-6075 CELL 508-958-4874 _ EMAIL andy(cD,hphCllc.corn kecia©hphcllc.corn a @1 Ik 11 I 1 r The Commonwealth of Massachusetts - Department of Industrial Accidents Offi of Insti u t500ce Washingtonve Street Boston,MA 02111 www.mass.gov/daa Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Ittdividuat): Harwich Port Heating&Cooling LLC l li Address: 461 Lower County Road . I e City/State/Zip; Harwich Port MA 02646 Phone#: 508-432-3959 a Are you an employer?Check the appropriate box: Type of project(required): ,. 1.12 I am a employer with 75 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub contt actors 6. g New aonstniction i 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. g Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition • working for me in any capacity. employees and have workers' 1 [No workers'comp.insurance comp.insurance. # 9. Building addition required.] - 5. 111 We are a corporation and its 10.g Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.[A Plumbing repairs or additions t myself[No workers'comp. right of exemption per MGL 12.[]Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.P Other HVAC € comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Selective Insurance Company of South Carolina Policy#or Self ins.Lie.#: WC9059813 Expiration Date: 10/26/2020 Job Site Address: 47 SISTER CIRCLE City/State/Zip:YARMOUTH PORT, MA. 02675 E Attach a copy of the workers'compensation policy declaration page(showing the policy number anti 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 insuranc coverage verification. a I do hereby cert 'nd ' a dpenatties of perjury that the information provided above is true and correct. Signature: - Date: 8/27/2020 . Phone#: 508-432-3959 . Official use only. Do not write in this area,to be completed by city or town official I��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 j 6.Other . Contact Person: Phone#: . . .. . .- It e4 it 1 4