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HomeMy WebLinkAboutBLDP-24-48 ,, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK lt it el .•-,�qi- sfiniI- CITY South Yarmouth MA DATE 1/10/2024 PERMIT# ,(3L44'"2y—V� JOBSITE ADDRESS 200 Long Pond Dr OWNER'S NAME Garland Weaver P OWNER ADDRESS TEL 508-398-4572 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL ❑ RESIDENTIAL El PRINT CLEARLY NEW:U i RENOVATION: REPLACEMENT:LJ PLANS SUBMITTED: YES❑ NO0 FIXTURES 7 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I 1 Ii I 11 1 L L 1 I. l 1 L 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM —1 1 --1 L ,-- I 1_„-�_._._J DEDICATED WATER RECYCLE SYSTEM _ J T�I_I DISHWASHER DRINKING FOUNTAIN I, 1 I 1 FOOD DISPOSER 111111 FLOOR/AREA DRAIN - -_ -_._-__ --1- —1 i INTERCEPTOR(INTERIOR) 1' KITCHEN SINK i i z 1 r LAVATORY 1 - 1 �_ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET I____ J-�� 1 � . _ _ URINAL WASHING MACHINE CONNECTION I Plit e : _'T1111 WATER HEATER ALL TYPES 1 ! 7 - - ( WATER PIPING J L 1. ' 1 H1 OTHER _...� rwr !L_._1 ® + r . 'Ai _ _ I � .)INC Li- MEN f 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 0 BOND Ji 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 LI AGENT 1 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. L. 1 k ,t.v-L PLUMBER'S NAME Michael Maille LICENSE# 11355 SIGNATURE MP IJ JP❑ CORPORATION❑# PARTNERSHIP❑# LLCQ# 3609 I COMPANY NAME HomeServe USA Energy Services NE LLC ( ADDRESS 5 Constitution Way CITY Wobum STATE MA ZIP 01801 TEL 781-359-2606 FAX CELL EMAIL Rachel.whittick@homeserveusa.com 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 i i Inc t,vinmeiicrveucen uJ lntuaauciivaeet:;:**,;>COMMONWEi4LTH OF M • Viu iU.mc i:<a=1 • • \ • • '1 • \ , Department of Industrial Accidents s ql~ v " " Office of Investigations PLUMBERS AND GASFITTERS 1} .,, Center TCENSE " Lafayette City ISSUES THE FOLLOWING L .yam; u0 ~�, '_ 2 Avenue de Lafayette, Boston,MA 02111 MASTER PLUMBER �� WWW.mass.gov/dia MIGHAEL J MAILLE Workers' Compensation Insurance Affidavit: Builders/Contra*r 4a srlol Applicant Information DRACUT,:<MA 01826-2030 :::.< >< Name (Business/organization/Individual):HomeServe USA Energy Services NE L 11355 05i0112024 > 215536 Address: 5 Constitution Way :• - _ City/State/Zip: Woburn/MA/01801 Phone#: 781-359-2620 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 50 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. Building addition required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.111 Roof repairs insurance required.] t c. 152, §1(4),and we'have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 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: Zurich American Insurance Co. Policy#or Self-ins. Lic. #: 292689003 Expiration Date: 7/1/2024 Job Site Address: All Locations City/State/Zip: ' 7-k-i` (IA.tix&L„ (. Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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: I�'�` w-- I��"--- Cam---' Date: 7/10/2023 Phone#: 781-359-2620 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): lDBoard of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5 f Plumbing Inspector 6.0Other Contact Person: Phone#: cuenrw: 1 rszsn 1 HOMESUSA DATE(MM/DD/YYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE 6128I202L- 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 any rights to the certificate bolder in lieu of such endorsement(s). PRODUCER CNAMECT Michele Lanzalotti USI Insurance Services LLC PHONE 610-897-4407 FAX No): (NC,No,Ext): 1787 Sentry Pkwy W.,Veva 16 E-MAILDRSS: michele.lanzalotti@usi.com Suite 300 INSURER(S)AFFORDING COVERAGE NAIC# Blue Bell,PA 19422 INSURER A:Zurich American Insurance Company 16535 INSURED INSURER B•Allied World National Assurance Company 10690 HomeServe USA Energy Services NE LLC INSURER c:Travelers Property Cas.Co.of America 25674 5 Constitution Way,Suite B . INSURER D: Woburn, MA 01801 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. LTR TYPE OF INSURANCE INsR ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP UMITS (MMIDDIYYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY GL0292689303 07/01/2023 07/01/2024 EACH OCCURRENCE $2,000,000 CLAIMS MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $1,000,000 MED EX?(Any one person) $10,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: • GENERAL AGGREGATE $4,000,000 POLICY X JECTT X LOC PRODUCTS-COMP/OPAGG $4,000,000 OTHER: $ A AUTOMOBILE LIABILITY BAP292689403 07/01/2023 07/01/2024 COMBINED SINGLE UMIT (Ea accident) $2,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED - SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED X AUTOS ONLY X PROPERTY DAMAGE AUTOS ONLY (Per accident) $ $ B X UMBRELLA LIAR X OCCUR 03106305 07/01/2023 07/01/2024 EACH OCCURRENCE $9,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $9,000,000 C DED X RETENTION$$10,000 EX6T23090523NF 07/01/2023 07/01/2024 Excess Liab. $10,000,000 A WORKERS EMPLOYERS' COMPENSATIONSLILIABILITY WC292689003 07/01/2023.07/01/2024 X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE FR ANY IVE 0 ICER/MEMBER EXACLUDEEED?ECG N N/A EL EACH ACCIDENT $1,000,000 (Mandatory in NH)Eyes,describe under EL DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POUCY LIMIT $1,000,000 I i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Coverage • CERTIFICATE HOLDER CANCELLATION Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEI I SD BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD ftS40560429/M40541110 JBCZP