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HomeMy WebLinkAboutBLDP-23-004489 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK S;e CITY YARMOUTH MA DATE 2/13/23 PERMIT# BLDP-23-004489 x` JOBSITE ADDRESS 22 WILLOW LN OWNER'S NAME ARENA JOHN A P OWNER ADDRESS ARENA DIANE F PO BOX 4999 1 LAMPLIGHTER WAY MT HERMON,MA 01354 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO 0 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 DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR/AREA DRAIN _ INTERCEPTOR(INTERIOR) _ KITCHEN SINK LAVATORY 1 ROOF DRAIN _ SHOWER STALL 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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. PLUMBERS NAME Robert Lamica LICENSE 3>2001 SIGNATURE MP 0 JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ROBERT M LAMICA ADDRESS 17 David St CITY Southampton STATE MA ZIP 010739496 TEL FAX CELL EMAIL .L, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ®s - PERMIT# 8( DP 23-1Y. _ li - `z CITY �, . . 110 1"�1_ „,._ MA DATE i 2 2'3 JOBSITE ADDRESS 2_2 W I I)OIA) Lane_ ! OWNER'S NAME \Tack Arena_ OWNER ADDRESS Sarne. a TEL - 237_ZZS FAX[ 1 TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL __j RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES` NO FIXTURES -1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB j 31 CROSS CONNECTION DEVICE i DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM • DISHWASHER _ • p ' DRINKING FOUNTAIN , ' i I 1; FOOD DISPOSER _.. . ,I ---fl. .__ I ._ 1n FLOOR/AREA DRAIN • ..__ INTERCEPTOR(INTERIOR) I KITCHEN SINK r= 4 It tI LAVATORY I J -11 ._--._ ROOF DRAIN 1 __ i ' _ __-. �,� SHOWER STALL it SERVICE/MOP SINK TOILET t` URINAL I- 7---11— WASHING MACHINE CONNECTION j `; �- ; WATER HEATER ALL TYPES d (i , WATER PIPING — OTHER Iig s• INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES v 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 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 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 it all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Robert Lamica LICENSE# 17058-M SIGNATURE MP , JP CORPORATION • # PARTNERSHIP)T#': LLC #' COMPANY NAME DF Plumbing, Inc. ADDRESS PO Box 1086, 9 Stadler Street CITY Belchertown STATE I MA ZIP 01007 y TEL '413-323-6116 FAX ;413-323-7532 CELL EMAIL dfplumbingbelchertown@yahoo,com II J..40 DFPLUMB-02 ALYSSA ACo/2O° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �/ 2/2/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Alyssa Perusse NAME: Phillips Insurance Agency,Inc. PHONE I FAX 97 Center Street (A/C,No,Ext): (A/C,No): Chicopee,MA 01013 n oRlEss:alyssa@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Middlesex Insurance Company INSURED INSURER B: D.F.Plumbing,Inc. INSURERC: 9 Stadler Street INSURER D: Belchertown,MA 01007 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYYI IMMIDD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR A0194493003 1/6/2023 1/6/2024 DAMAGETORENTED 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY X PRO- LOC 2,000,000 JECT PRODUCTS-COMP/OPAGG $ OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO A0194493004 1/6/2023 1/6/2024 BODILY INJURY(Per person) $ OWNED X SCHEDULED AUTOS ONLY _ AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE A0194493006 1/6/2023 1/6/2024 AGGREGATE $ 2,000,000 DED X RETENTION$ 0 $ A WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER A0194493005 1/6/2023 1/6/2024 500,000 ANY OFFICER/MEMBEER/EXCLUDEDX?ECUTIVE N N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000, DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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