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HomeMy WebLinkAboutBLDP-23-11811 7 ,_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK k.raltez y CITY-F-- #�`2illevT . MA DATES u/// 2c'23 ]PERMIT# $L:1 - L3r./.4 ". L, JOBSITE ADDRESS I I e,3 <re a`' OWNERS NAME l/-I C 7\1 P OWNER ADDRESS 1 .7-n o_ "C'o w P/1_ l TEL'S t' '7 ..4.6 6 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ET EDUCATIONAL 1 1 RESIDENTIAL El PRINT CLEARLY NEW:[ RENOVATION:0 REPLACEMENT:4 E St PLANS SUBMITTED: YES I 1 NO1 i FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB i MR_ $ ;,--f : i il�_--_ .jFi ai i.— CROSS • • I — l - —_ -I WATERDEDICATED GRAY WATER SYSTEM MIUMWIJMINIIEIIMIIIMIMMFMMMIIILIBMMT DEDICATED I FLOOR/AREA DRAIN it-iimmatianguannua LAVATORY i -- .- --r-----r- : 1— :— , , 1, i, ic :, :r----i ROOF DRAIN TOILET URINAL .!:- __.: -__ 1;1 __.. ' ....., ____ , , . ; .; :Iimin —7 i _ WASHING MACHINE CONNECTION I— r! ;{ WATER HEATER ALL TYPES .1*--7;7-_-__. ._ 1 -1:-;l'"'----EMI - litawnito :, �" (1i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E No F+ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE By CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTOTHER TYPE OF INDEMNITY; 1 BOND E 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 {I 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 6-J'4-i-1,1," /4C 4-771 �<- —+ jLICENSE#i 1 Z'`/ 1 SIGNATURE { - MPv JP 3 CORPORATION ]# ._ �1PARTNERSHIP--#� LLC 0#1 - COMPANY NAME /11/ Je-L✓!c,- 6,, ADDRESS 1 5'1-' m N S3 e 7" { CITY _rpm()t,J, -G, STATE 1 tr,n- Bp[62 S.6 3 1 TEL t 5o0 7 7 4 /O i7 S FAX 10ELL ?7Y YY7 I 3r//s.�/=T DU 6) 1c�.nor:/. ( , The Commonwealth of Massachusetts k . Department of Industrial Accidents .�, "t 1 Congress Street, Suite 100 =o•WatNi =< 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 Legibly Name (Business/Organization/Individual): '.."3 4 S e tz_v 1 C (a vn e/4 aJ,4 Address: 'IS- niA-r tJ S 72 t E; City/State/Zip: 'Swo W,c 1. NIA- 02SM6 3 Phone #: SJ 77 6 I OD Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).' ❑ 7. ®"New construction 20'1 am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.13I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q 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 11.0 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. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.QOther 1A-V 4 152,§1(4),and we have no employees.[No workers'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. *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. 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: Al W') Ill t.ITi)i 1- I►'JS U rtAA)C.l; Co vvt()1 n1 1 Policy#or Self-ins.Lic.#: 'W C_C--S00—SD 2-92 o'er —70 z 3 4(1)Expiration Date: 40 - 1 — 20 2 1/41 Job Site Address: City/State/Zip: 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$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 perjuty that the information provided above is true and correct. Signature: :: Date: -/ t V .v L Phone#: Uy, —TN, f Uor` 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#: Ac o®oR CERTIFICATE OF LIABILITY INSURANCE DATE 8(MMID(MM/DD/YYYY) /Y /9/2023 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 NAME: Eastern Insurance Group LLC PHONE Helen Medeiros FAX 233 West Central St (A/C,No.Ext): 800-333-7234 (A/C,No):781-586-8244 Natick MA 01760 ADDARESS: CSR24CL@easterninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Insurance Co 41360 INSURED WILLHEA-01 INSURERB:Associated Employers Insurance Company 11104 William Heath Jr B & H Service Co INSURER C: 45 Main St INSURERD: Sandwich MA 02563 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1787952772 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/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY 8500058801 4/12/2023 4/12/2024 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO POLICY X JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY 1020045601 • 8/26/2022 8/26/2023 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $Included AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC-500-5029307-2023A 6/1/2023 6/1/2024 PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Sandwich 145 Main Street AUTHORIZED REPRESENTATIVE Sandwich MA 02563 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AjlibN�1...11 Ubtl 1b DRIVER'S '3' °4 LICENSE �� `NOT FOR FEDERAL ID Certificate of Completion , cFedi� ,tate Refrigerant Transition and Recovery ;lip =-_ - -7 1 411812020 11E2535112 Univei!sity Certification Program Dos t 04i2025 04/04I1959 ____ L u' a REST -Ew �� For successful completion of the Refrigerant NONE NONE Transition and Recovery course and tests, t 1M• this individual has been granted rar�nttion * , K 1 2 WIL • 0,JR �,:-„„,,,„:.-,,,tr..,,, _ in the following areas of commercial service ` ' i s45 MAIN ST SANDWICH,MA 02563.2133 ,_ WIWAM 0 HEATH JR / ,::erEs HAZ t;sac M 15 HOT 5'-09" t C ir 5 DO 0419/202 Rev D2J2v i i _ 0 /04/59 017522_�?' Typo II,III r Cott:mar go• Cateries rt COMMONWEALTH OF MASSACHUSETTS _ _._____. DIVISION OF OCCUPATIONAL LICENSURE Refrigerant Transition and Recovery Certification Program ' SHEET METAL WORKERS s Certificate of Completion ISSUES THE FOLLOWING LICENSE . LLI �.` MASTER-UNRESTRICTED � �►�y a /'fVV1\ - WILLIAM 0 HEATH JR 0 "r°'e...,, dk...• has been certified as 45 MAIN STREET W �STe7 W SANDWICH,MA 02563 rn UNIVERSITY technician as required by 40 CFR Part 82, Subpart F • 13413 04/28/2025 440450 carte jorlNr.lber LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER • PApreir APNOt1Ak ONMw IS.IRS • COMMONWEALTH OF MASSACHUSETTS v COMMONWEALTH yr o - DIVISION OF OCCUPATIONAL LICENSURE DIVISION OF OCCUPATIONAL LICENSURE BOARD OF BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE PLUMBERS AND GASFITTERS JOURNEYPERSON-UNRESTRICTED s ISSUES THE FOLLOWING LICENSE n MASTER PLUMBER `a WILLIAM O HEATH JR a o 45 MAIN STREET W WILLIAM Ocln1 t20?d 1 h�l�l O HEATH JR ,w SANDWICH, MA 02563 z 4;MAIN STREET SANDWICH,MA 02563 J 4 12151 04128/2025 440451 ,nn�1 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER _ P COMMONWEALTH OF MASSACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE Commonwealth of Massachusetts BOARD OF ' Department of Fire Services BU-024086 PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE Oil Burner Technician Certificate JOURNEYMAN PLUMBER cc WILLIAM 0 HEATH,JR I. .---4 ; WILLIAM 0 HEATH JR Z 45 MAIN STREET ! _ - 45 MAIN STREET SANDWICH MA 02563 adit SANDWICH, MA 02563 V. J State Fire Marshal iZ- • Expiration Date 23489 05/01/2024 / 04/04I2025 202970 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER Commonwealth of Massachusetts Division of Occupational Licensure Pi efftter rlCIIr, P •. flaey4PHCP-W F PJ-030573 IlXpires 04/04/2024 WILLIAM O LATH, JR 45 MAIN STREET r = SANDWICH NtA 02563 * l , 1 t Commissioner 1i. `t &Jt..