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Home My WebLink AboutBLDP-20-001579 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CrfYrrowN SOUTH YARMOUTH MA DATE 9/17/19 PERMIT#a pe a -6 D is 27 .Ertl_s• 109 RIVER STREET JOBSITEADDRESS OWNER'S NAME MCCARTHY POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Igl PRINT CLEARLY NEW:J RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO VI FIXTURES T FLOOR-4 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/01L/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _ I FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 3 ROOF DRAIN SHOWER STALL 1 _ SERVICE/MOP SINK TOILET 2 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 DINO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY R ' 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application era true and accurate to the best of my knowledge end 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 Andrew Levesque LICENSE# PL15162 NATLYSM MP g MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC i# 3944 COMPANY NAME Harwich Port Heating &Cooling LLC ADDRESS 461 Lower County Rd CITY Harwich-Port STATE MA ZIP 02646 TEL 508-432-3959 FAX 508-432-6075 CELL 508-958-4874 EMAIL andy(a7hphclIc.com The Commonwealth of Massachusetts t_�_,= Department of Industrial Accidents alt=tr= 1 Congress Street,Suite 100 .,@[4i� _.• Boston,MA 02114-2017 www mass.gov/ilia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/PIumbers. TO BE FILED WITH PERMITTING AUTHORITY. Apnlicant Information Please Print Legibly Name(Business/Organization/Individual):Harwich Port Heating&Cooling Address:461 Lower County Road City/State/Zip:Harwich Port MA 02646 phone#:508432-3959 Arc you an employer?Check the appropriate box: Type of project(required): I.Q I am a employer with 75 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.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]f 9. ❑Demolition 10❑Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my 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. 12.1:Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.QRoof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑✓ Other HVAC 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box ff1 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. tContractors 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:AmGuard Insurance Company Policy#or Self-ins.Lic.#:HAWC772249 Expiration Date:1 0/26/2017 Job Site Address: 109 RIVER STREET City/State/Zip:SOUT YARMOUTH, MA 02664 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 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 t e p i> ena'ies of perjury that the information provided above is true and correct. Signature: Date: 9/17/19 j Phone it:508-432-3959 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1