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Home My WebLink AboutBLDP-21-004309 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK F CITY YARMOUTH MA DATE 1/30/21 PERMIT# BLDP-21-004309 .Py JOBSITE ADDRESS 136 WIMBLEDON DR OWNERS NAME GUIDE JOSEPH A P OWNER ADDRESS FEDERICO DONNA M 14 HERITAGE DR WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES -1 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 1 DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 5 LAVATORY 1 ROOF DRAIN SHOWER STALL 3 SERVICE/MOP SINK TOILET 1 3 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER 1 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D 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. PLUMBERS NAME Peter Farricy LICENSE f5042 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Peter F Farricy ADDRESS 91 Middlesex St CITY Millis STATE MA ZIP 020541015 TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY wi, 7rr-rmo- 11 MA DATE ( _ 2°A 1 PERMIT# JOBSITE ADDRESS i 3 bIc L ,, sA OWNER'S NAME � � R. II OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL- PRINT CLEARLY NEwergi RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOS FIXTURES Z FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I _ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ , DEDICATED GAS1011../SAND 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 �S ROOF DRAIN SHOWER STALL 3 SERVICE/MOP SINK TOILET I 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. YE9t, NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY_ OTHER TYPE 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and curate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli II Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME b'e•tt-x ( t. y LICENSE# /50`f L SIGNATURE MIDIS- JP❑ CORPORATION 0# PARTNERSHIP 0# _ COMPANY NAME 1-,,_(/:C_- ( � ,,c.L H rl e-c� /d-� ADDRESS go/. ( r ` CITY 1 1 STATE /14 k ZIP Cl 2c/ l TEL A 9 s. 21121 ti FAX CELL SoVI C/6 a 2 ; 7 r, 7 L i t 1 EMAIL cr�rl �I��.1,_4- .f = t3LllLDlN DE'-i rile-- F dr The Commonwealth of Massachusetts It Department of Industrial Accidents Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lexrbly Name(Business/Organization/Individual): fiehr i Address: ea ge)( 40 L , City/State/Zip: /1, Si Phone#: i 0r goo 62.71 Are you an employer?Cbaktbe appropriate box: Type of project(required): I.❑l am a employer with employees(full and/or part-time).• 7. ❑New construction • 2,g..jwo a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all workmyself 9. ❑Demolition ❑ g [No workers'comp.insurance required.)t 10❑Building addition 4.0 I 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.❑Electrical repairs or additions proprietors with no employees. 12.aPlumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. I3.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation end as officers have exercised their right of exemption per MGL c. 14.❑Other 152,1.1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box al 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 than hire outside contractors must submit a new affidavit mdeoryng 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.lithe sub-contractors have employees,they mutt provide their workers'comp.policy mmaber. I one 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-ins.Lic.#: F Expiration Date: Job Site Address: 13I 1✓`,t d Ld S City/State/Zip: N/4-'''‘,1k 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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( , the pains and penalties of perjury that the information provided above is true and correct. Si nature: �wv Date: 1/2G/21 Phoned: 57?(No L17I 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#: