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HomeMy WebLinkAboutBLDP-17-006455 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -1 CITY (n) .L1-14�1-,0— MA DATE PERMIT# !3/-R7—/ —61641/53 � p � �,/n n i Q �., JOBSITE ADDRESS IS- 1-nACPP„3tnCt Qc OWNER'S NAME .QJr-en JI V e.6-c OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:IS, PLANS SUBMITTED: YES❑ NO❑ FIXTURES Z FLOOR—, 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 SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN ItIN %'fa INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY a ROOF DRAIN SHOWER STALL ►- SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Vr. 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. 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 i.ri7jan h all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Y ae-t42.` LICENSE# I caoo SIGNATURE MP® JP❑ CORPORATION El# PARTNERSHIP El# LLC[a# �-I cY-I `7 / COMPANY NAME C.G�s)c ���-$ �,f 1��.-� �j <QADDRESS X I"' `'4-3 �`k fU�s- 'jj7• 9Y9 CITY S ,`1'ari-o•�4 STATE h/9 ZIP 0 c/ TEL FAX CELL SOLI_ )%- )1M EMAIL T45,.c (oc& 2 c. .c 0— Client#: 764315 2COASTALPLI ACORDn. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)06/06/2017 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 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: Dowling&0'Neil Insurance Ag PHONE 508 775-1620 FAX 5087781218 (A/C,No,Ext): ,LA/C,No): 973 lyannough Rd, PO Box 1990 E-MAIL Hyannis, MA 02601 ADDRESS: 508 775-1620 INSURER(S)AFFORDING COVERAGE _ L NAIC# INSURER A:Ohio Security Insurance Company 24082 INSURED Ohio Casualty INSURER B: Group Coastal Plumbing &Heating LLC INSURER C: 299 Whites Path INSURER D: South Yarmouth, MA 02664 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. INSRL 1ADD TYPE OF INSURANCE NSRL WVD POLICY NUMBERJ SUBR MMIDDY/YYYYL(MM DDY/YEYYYL LIMITS A GENERAL LIABILITY BKS1857846378 01/04/2017 01/04/2018 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMI ES(RENTED PREMISES ET occurrence) $300,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $1 5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 PRO- POLICY JECT I LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ __ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION XWO1857846378 01/04/2017 01/04/2018 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N 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(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insurance coverage is limited to the terms,conditions, exclusions, other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived, or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 134 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE c. .-�""A _ ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #5191714/M191699 LS1 1/2