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Home My WebLink AboutBLDP-21-003123 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 12/2/20 PERMIT# BLDP-21-003123 JOBSITE ADDRESS 3206 HEATHERWOOD OWNER'S NAME LARSON JESSIE P CO-TRS P OWNER ADDRESS LARSON ALLEN R CO-TRS 3206 HEATHERWOOD YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: 0 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING 1 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#7074 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 FEES$ PERMIT# PLAN REVIEW NOTES 4/2 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ` (�-Z(-d,t31)\ lit_ CITY/TOWN YpkM o u r A P o irt--- MA DATE //- Z 6. za PERMIT# JOBSITE ADDRESS 3 Z O 6 w d c c/ OWNER'S NAME 04tR/Ci1 f 4 if 4s OWNER ADDRESS 32 0 (. 4274pee L,emac,ci TEL FAX TYPE OR OCCUPANCY TYPE • COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY i NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR— BSM 1 2 3 I 4 5 6 7 B 9 10 11 12 13 14 BATHTUB ' CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM T DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM i DISHWASHER / DRINKING FOUNTAIN FOOD DISPOSER I FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK / LAVATORY j ROOF DRAIN SHOWER STALL / SERVICE/MOP SINK / TOILET Z„URINAL .,._FLI ....:._... " WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER • l . INSURANCE COVERAGE: I have a current liability insurance policy or its subst al equivalent which meets the requirements of MGL Ch.142. YES NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TY OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY 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 0 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. PLUMBERS NAME/1I/4j*L. 6 .c p i 4 5tit LICENSE# / 26 Lj' SIGNATURE MP❑ JP.;-1/ CORPORATION El# PARTNERSHIP❑# LLC❑# COMPANY NAME '7Vc:l�s G S p4i¢., ADDRESS ec r �Lv� CITY tL/L y'4 . STATE/ 19 Zip (52 2 3 TEL 0(4' 2e Z 0/8g FAX /(/G CELL`3" ' 9 L L O /Se EMAIL /L-r-" -e The Commonwealth of Massachusetts / Department of Industrial Accidents ®�= § 1 Congress Street,Suite 100 =s'=— Boston,MA 02114-2017 's.. ,,ma www mass.govldia ~ Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(13usinessiOrganization/Individual): 73-11 C 141(.G pa- 4-57(.f,.( Address: .2-9 Pa-G 5)c-.-1 City/State/Zip: AV- )C,q_a P`) Phone#: ( C u_ �7 Z C"! g G Are you an toyer?Check �the tappropriate box: Type of project(required : 1. am a employer with employees(full and/or part-time).* 7. New con On 2. I am a sole proprietor orpartnership and have no employees working for me in 8. odeling capacity.[No workers'comp.insurance required.] 3.0 t am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 10❑Building addition 4.❑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 pmprirtors with no employees. 12.❑Plumbing repairs or additions 50 1 am a general contractor and I have hired the sub-contactors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per Ma.c. 14.D Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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. tContradors 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 member. I am 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.#: Expiration Date: Job Site Address: 3 2' W O(7 r� City/State/Zip: )/4 sty p '' r" Attach a copy of the workers'compensation policy declaration page(showing the policy n tuber 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 the pains and penalties of perjury that the information provided above is true and correct. Siirrtature z � Date: /l a�o ` Z-GZ G Phone#: - J Z c:C 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 Phone#: Contact Person: