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Home My WebLink AboutBLDP-21-004571 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1:,)( 1„,, CITY YARMOUTH MA DATE 2/11/21 PERMIT# BLDP-21-004571 JOBSITE ADDRESS 1208 HEATHERWOOD OWNER'S NAME CHATZINAKIS MARIA TR P OWNER ADDRESS THE MARIA CHATZINAKIS LVG TRUST 1208 HEATHERWOOD YARMOUTH TEL PORT,MA 02675 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 1 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❑ 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 Michael Sprague LICENSE W074 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME MICHAEL E SPRAGUE ADDRESS 28 PROSPECT AVE CITY WEST YARMOUTH STATE MA ZIP 026734780 TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT El ❑ FEES$ PERMIT# PLAN REVIEW NOTES 3 t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK f_ CITY 74a. pc 2 r MA DATE 2 - / G-24-z/ PERMIT#BO)P CotiS1j JOBSITE ADDRESS /2 OR �.91,few w c a I> OWNER'S NAME E. E41/0/L L 8 PIQNI e2 OWNER ADDRESS /Z G g Z-4 4 7'4.R ki o c TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENT PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR-F BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM j DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM • DEDICATED WATER RECYCLE SYSTEM DISHWASHER • DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 ROOF DRAIN _ SHOWER STALL f SERVICE I MOP SINK TOILET / _ URINAL . j WASHING MACHINE CONNECTION , WATER HEATER ALL TYPES WATER PIPING OTHER _ j 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 OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY 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 11 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. %/Zet" PLUMBER'S NAME 1�'-rG /_ - eR�1 ? fr� LICENSE# 1 14)09Y j� IGNAT E MP ❑ JP� CORPORATION❑# PARTNERSHIP❑.# LLC❑# / 7 G 7 y COMPANY NAME M't c1/!< < E _5720 t' ADDRESS 0 P 2 G fpt e 47s�P CITY lit/ , x4a STATE /9 ZIP o ZG 2,3 TEL z G/EE FAX Arc;a -i CELL 6 C_ '22 -C/e is EMAIL A7'Gry 'r ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite lOt) Boston,MA 0114-2017 www.mass.gov/din Workers'Compensation Insurance Affidavit:Builders/Contractors/ElectriciansfPlumbers. TO BE FILED WITH THE PERMITTING AL PROBITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): �'c4e-G E �2R </4 2 t, p L S •f- 74- Address: 2 c cAc Sip c c t City/State/Zip: kV, v?. /fj , 0,-?-6>3 Phone#: 2'2 2- — C1 c Are you Toyer?C the appropriate box: Type of project(r ed): 1. am a Dyer with C employees(full and/or part-time).* 7. El New nstruction 2: a sole proprietor or partnership and have no employees working forme in , 8. emodeling any capacity.[No workers'comp.insurance required.) 3.01 am a homeowner doing all work myself[No woikws'comp meorance required.]t 9. Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workcers'comp.insurance.' 1 •❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other rp ffi 152,§1(4),and we have no employees.[No workers'coop.insurance required.] *Any applicant that checks box n 1 must also fill out the section below showing their wonders'compensation policy information. t Homeowners who submit this affidavit indiratine 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. . Insuranr'Company Name: ^ Policy#or Self ins.Lic.#: Expiration Date: Job Site Address: 2 0 8A/4 tyIState/Zip: pGr2 f //ji•�. 02Gc>J' ��o {� W�c r� Ci �� Attach a copy of the workers'compensation policy declaration page(showing the policy n ber and expiration date). Failure to secure coverage as required under MGL G.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 the pains and penalties of perjury that the information provided above is true and correct Signature:— Date: 2 C - ( Phone#: 7(f- S2 Z - C/w 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#: