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HomeMy WebLinkAboutBLDP-23-11829 ./ 3 t 'F2i7.TJez_e-s ..230 N tc' 3 - I c>_ C,c-, 'Th-c, ,a( 3 t0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK MA DATE CITY # )�I�b�1 it - - I- //E/Zc 3 1 PERMIT#B '�-4/?2 JOBSITE ADDRESS I I.4>-3 r'-re Z€ wr_ 1 OWNER'S NAME l/-1L C v\I P OWNER ADDRESS TEL s-o f3 7 7/ . 6 6 C FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL[- ' EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:C RENOVATION:0 REPLACEMENT:: ': PLANS SUBMITTED: YES ri NO FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB -.. __ DEDICATED SPECIAL WASTE SYSTEM imetwiminimmminimmtmusiumism MINIIMI CROSS CONNECTION DEVICE DEDICATED GAS/01USAND SYSTEM :—... . .i _1 ii-wi __10, DEDICATED GREASE SYSTEM I 6 _ DEDICATED --.7 I MR OO11 •O l I :I-, INTERCEPTOR(INTERIOR) L ° _ (mIKITCHEN SINK :__ 7_, __„,::::11—__. 1 _-4,:—..._:____-_i ' a 'i- ' : rY i i ROOF DRAIN �p �i -----.- _ URINAL 1 -:- r <__,__I ---, -- 't ____11- "' ' - -M,..-i'llinili-E,N1 is _ II. W _ _ iiM 11.111 i +—UMW _ ___111111imium INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES;H NO Li IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE OF INDEMNITY 1 BOND L ^-I 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 I I AGENT Li 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! G.,),cc Ir)r" lit-/r'Tff r'� -~�ILICENSE#l I Zc' / I � � SIGNATURE MP E-j JP❑ CORPORATION __-- IPARTNERSHIPD#1 - I LLC L_1#1 -i COMPANY NAME '--/,L .s-e-L✓1c1 --ram ‹`A`:, :? i ADDRESS I `i'S' rli,/y„/ J 7 cl 7 i CITY SA,, i ,,c.-G, 1 STATE 11e/}- J ZIP[ 02Y-6 3 1 TEL 15 2 7 4 /O t?j- FAX I I CELL I'?I Y Ye 1 EMAIL , i //s J,T l3v t'-. .:n4.:/. 6.).-07r - iC The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 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): j 4. t-t S etzv i CC C-0 ry (94011 Lr) Address: `/S tv?fti 1 ST2.e€r City/State/Zip: &NOW GA, MA- 02S-6 3 Phone#: SD 0 77 6 100 Are you an employer?Check the appropriate box: Type of project(required): 1.p I am a employer with employees(full and/or part-time).* 7. ©New construction 2.0•1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.12 Electrical repairs or additions proprietors with no employees. 12.©-Plumbing repairs or additions 5.0 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.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other ,✓ 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. 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: A I W1 l'11 t rtl L i JS v KAAks rA Policy#or Self-ins.Lic.#: W C --S00-.SJ a-92 0'7 -Z'Z 3 4(/)Expiration Date: (o - - ZO 2 V 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 perjury that the information provided above is true and correct. Signature: Date: AA V I ZO 23 Phone#: S O', 77( (Dar- 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#: ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 8/9/2023 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 Helen Medeiros Eastern Insurance Group LLC PHONE FAX 233 West Central St (A/c.No.eat):800-333-7234 (A/C,No):781-586-8244 Natick MA 01760 ADDRESS: CSR24CL@easteminsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Insurance Co 41360 INSURED WILLHEA-01 INSURER B:Associated Employers Insurance Company 11104 William Heath Jr B & H Service Co INSURER C 45 Main St INSURER D: 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 ADOL SUBR POUCY EFF POUCY EXP UNITS LTR INSD WVD POUCY NUMBER (MMIDDIYYYY) (MM/DDIYYYY) A X COMMERCIAL GENERAL LIABILITY 8500058801 4/12/2023 4/12/2024 EACH OCCURRENCE $1,000,000 GE 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 X POLICY PRO- 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 UAB _ 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 YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBE2 EXCLUDED? 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 POUCY PROVISIONS. Town of Sandwich 145 Main Street Sandwich MA 02563 AUTHORIZEDREPRESENTATiVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ilV1ti.bWit in Ua�1-.1-S DRIVER'S - �: LICENSE Certificate of Completion .r NOT FOR FEDERAL ID GFed-ks State `� f,r 'c Refrigerant Transition and Recovery 4l18/2020 522535112 vI11VC:Sit}T . Certification Program it ix Doe 0410412025 04/04/1959 AN.— " ewe REST ,-em r^� Fa successful completion of the Refrigerant ""f, -Ott NONE NONE /�1 Transition and Recovery course and tests, _' HEATR this individual has been granted recognition is 21 WILLIAM 0,JR &_ : as _.. in the following areas of commercial service `•' • -s 45 MAIN ST 4, , SANDWICH,MA02563.2133 > tinz _ _ ^1MWAM 0 HEATH JR SEX M 16HGT 5'-09" s 1 DDON19/2020 Rev 02/27/2016 04/04/59 0175226'17 Type II,Ill COMMONWEALTH OF MASSACHUSETT ' DIVISION OF OCCUPATIONAL LICENSURE BOARD O Refrigerant Transition and Recovery Certification Program ` SHEET METAL WORKERS Certificate of Completion ISSUES THE FOLLOWING LICENSE . MASTER-UNRESTRICTED IE �� a . WILLIAM 0 HEATH JR g k Calitesp tatireo• has been certified as 45 MAIN STREET W ors STATE W SANDWICH, MA 02563 1n UNIVERSITY technician as required by 40 CFR Part 82, Subpart F • 13413 04/28/2025 440450 CwtEcelbnNmrbgr LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER 11PA IhragnieiAroma QOIwr IS,11113 * COMMO WEALTH OF MASSACHUSETTS v COMMONWE ALTP i DIVISION OF OCCUPATIONAL LICENSURE ::DIVISION OF OCCUPATIONAL LICENSURE BOARD OF BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE PLUMBERS AND GASFITTERS to JOURNEYPERSON-UNRESTRICTED a ISSUES THE FOLLOWING LICENSE a MASTER PLUMBER WILLIAM 0 HEATH JR z d 0 45 MAIN STREET W WILLIAM 0 HEATH JR w' SANDWICH, MA 02563 z 4;MAIN STREET w SANDWICH,MA 02563 J 12151 04/28/2025 440451 ,,,,,ter 0 101190 4 19 .i.f 1r LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER _ V COMMONWEALTH OF M' ACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE' Commonwealth of Massachusetts BOARD OF tfDepartment of Fire Services BU-024086 PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE iu Oil Burner Technician Certificate JOURNEYMAN PLUMBER r- WILLIAM 0 HEATH,JR i�. WILLIAM 0 HEATH JR z 45 MAIN STREET SANDWICH MA 02563 45 MAIN STREET SANDWICH, MA 02563 N V State Fire Marshal ,z '--y Expiration Date 23489 04/0412025 05/01/2024 202970 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER Commonwealth of Massachusetts V. Division of Occupational Licensure PipefItter II(:, ''' peyl kPHCP-W F PJ-030573 y spires:04/04/2024 WILLIAM 0 IiJATN, JR. . 45 MAIN STREET _ _� SANDWICH MA 02563 t•, � Commissioner daft /. E&ini•G,a.