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Home My WebLink AboutBLDP-21-004680 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 2/18/21 PERMIT# BLDP-21-004680 r t JOBSITE ADDRESS 28 PHYLLIS DR OWNER'S NAME RACINE RICHARD G P OWNER ADDRESS RACINE CLAIRE A 28 PHYLLIS DR SOUTH YARMOUTH,MA 02664-1680 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ NO❑ FIXTURES 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 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 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❑ NO Cl IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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. 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 Spencer Hallett LICENSE 1;6224 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME SPENCER HALLETT ADDRESS 381 Old Falmouth Rd Unit 36 CITY MARSTONS MLS STATE MA ZIP 026481372 TEL FAX CELL EMAIL spencer@hallettplumbing.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ FEES S PERMIT PLAN REVIEW NOTES = I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK an, Yarmouth MA DATE 2/15/2021 PERMIT# t1-13P- 2(—°°4-1 b• =tlils JOBSITE ADDRESS 28 Phyllis Drive OWNER'S NAME Shaw J L r S 4- ap,„, OWNER ADDRESS 28 Phyllis Drive South Yarmouth TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:IY/ PLANS SUBMITTED:YES❑ NO❑ FIXTURES 1 FLOOR-, ABM 1 2 3 4 5 8 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND 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 1 • ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: �/ I have a current)lability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch,142. YES pQ NO❑ IF YOU CHECKED YES,PLEASE INDICATES THE/ TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY pd 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 Genera;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 best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will bo In compliance with al a ant Yovislon of the Massachusetts State Plumbing Code and Chapter 142 o1Ihe General Laws. PLUMBER'S NAME Spencer Hallett LICENSE#16224 MP:X JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Spencer Hallett Plumbing and Heating ADDRESS 381 Old Falmouth Rd Unit 36 CITY Marstons Mills STATE IAA— ZIP._D2648- TEL508-428-6080 FAX FOR-478-7991 CELL EMAIL spencer@halnllmbina com 3 i -i-C- _.E%-.�.f»L1-/Sf..1=p'�-£ 'r}a ,;.77, .t k•G:E'a�;• y�'�' i ed j� S 11 ---"4---1 '-- - riti7.c.f . 611.7FTTPosgs'a-elm7 r. .t. -::, - ---d - .gasp ra,MA 02111 t,.- y - 7- 1 W,..w goof . '_ Workers' ompeusaU0D.Iras-orave ok � ers • ae.(Bushicsy .rgatzagoendi inuat�: _ Spencer Hallett Plumbing and Heating , i Ad. ess: • 381 Old Falmouth Road, Suite 36 - s • City/State/Tip: Marstons Mills, MA 02648 Phone#: 508-428-6080 il Are your auk employer? Check the appx opti to boxy ' - • 1.D ram a employer with11 4. Li I am.a g-m ,.di eontractor Rmi Tie of proje r �•ec : 2.n employees a (HI an.d/or part i zzne).=� e hired the s�- ors-s 6• Cr);New construction sole proprietor or paha listed on the attached sheet 7. D RAn.ocleling ship and have no employees These sub-coltactixs have ' - �. El Iaero.oIiiicm I. working forme 'in any capacity. employees and have workers' [No workers' comp. insurance -Building addoIl CO�p. I2SllIc a I red- S- 0 We ale a corporation and 110 Electrical repairs or additions 3.DI am a homeowner doing al[work officers have exeak..ised their z II, Plumbing .,mg myself 'o workers' comp, . of ex roptionperMGL repairs or editions i urance required,.t C. 152, §1(4), and we have no 12. P oaf pairs earxployees_ {No wozkors' 13.F1 Otter r comp. fiance regpired_J ii 'Any applicant thaf checks box#1 most also 7 U ordthc section below showiu4'fleirworkrs1 wumczrsatiom policy iilforrnwtion. Homeowners who submit this affiaa.vit indicating they am doing U work aid then hz °nisido earhactors Est submit a n w azaday inrli ' r stick ICoutractors that check this box must attached ea almtioual shrY-t showing-the nasac 4£the sulmxratractiors ad state whelp-Dr not those sties have • fr ci uu ployrs. Tithe sub-- ntr=tors boo=player, they m-r st provide their work'comp.policy' bet. 5 I can an Toyer thr is pr'oputing work'=:s'corn sensation irzsrrrance for my employees. Below is tie-poky arum job s` `e 1. . inforfn n, ice CompanyNazne: The Hartford i Policy#or Sew ins. Lie. # 08 WEC AE8 RGA Expiration Date; 2/22/2021 'v i Yob Site.A.d+d s: 28 Phyllis Drive /st / :South Yarmouth MA 02664 j Attach a copy of the workers' c+3mpensatzoxt policy declaration page (showing tile po number and expiration date). • Failure to secure coverage as rag requnr-ed.uader Section 2 A of MGL c. 152 can lead to the imposition of criminal penalties of a foie up to $1,50.0 00 and/car one-yem-imprisonment,as well as aim penalties in the form of a STOP WORK ORDER and a tine of to $150.00 a - day against the violator, Be advised that a copy of s st.demeixt may be forwarded to the Office of Investigations of the DIA for ce coverage verfication., 11 I do hereby ccrtiff un e v.fper}rzry that the hzformatlon provided'above it true mid correct. Siima ore: 1 �: 2/15/2021 h Phone# 508-428-6080il - t ii Official use only. Do not i to in this area, to be conwreted by thy or town official - City or To : a - Permit/License se II IssucTrag Authority (circle one): L Board of Health 2, miming Department 3, City/Town Clerk 4.Electrical Inspector 5.PhanImpettor G. &.er n Contact Pexsun: • Phone • • 1 V w i • 1, ii