HomeMy WebLinkAboutBLDP-16-005020 , MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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- r`�' CITY 1 Lk)f-5; YA-i6no uTN I MA DATE I,31/ II(,. I PERMIT# l -I2 P-/6 -0760
JOBSITE ADDRESS --Pi /i)cG s-- OWNER'S NAME CA /5 DPN R I—o LEI
POWNER ADDRESS __ __ _____________ TEL 7SI-75i-8?)5 i FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL U EDUCATIONAL ® RESIDENTIAL El
PRINT
CLEARLY NEW:® RENOVATION:® REPLACEMENT:I PLANS SUBMITTED: YES® NO®
FIXTURES 1 FLOOR-* 8SM 1 2 r 3 4 5 fi 7 8 9 1D 11 12 13 14
CROSSBATHTUB CONNECTION DEVICE I Ili I ,011.1101111 i N I�'11" i ll.___ ,,11111111
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DEDICATED SPECIAL WASTE SYSTEM I � I I
:I DEDICATED GASl01LISAND SYSTEM l� ! i - II1 II __._ -� - ..____
DEDICATED GREASE SYSTEM I I' wallaaDEDICATED GRAY WATER SYSTEM I I 1I .I 'iDEDICATED WATER RECYCLE SYSTEM 1 • , ij ( 1
DISHWASHER i_ 1 I I I
DRINKING FOUNTAIN -,_ ,
FOOD DISPOSER _ I initar Mt=ME EIMIIIIIIR IMP
FLOOR/AREA DRAIN .111.11.11111111 IIIIIIIIIIIIIIt NOM IIIIII M IIIIIIIIIIIIIIIIIHNIII,
INTERCEPTORTRCE SiK INTERIOR --I111111.00.10.1111.1111.1.1111111111�'�'�' ;' I' I 1
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LAVATORY .� I
ROOF DRAIN - 1 j I I - , 'I l ,
SHOWER STALL 1 II I I II I, I II j
SERVICE I MOP SINK I '� I i i
TOILET it I _ l i ' ;I
URINAL i; y
WASHING MACHINE CONNECTION r I I I! l III
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WATER HEATER ALL TYPES I l
WATER PIPING I li 1 r ' ii
OTHER P
Mit IiIIIIIIIIIMINEWIL _ IM�r'M!—MIN MIi MIN Imo',
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142, YES U NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY k it OTHER TYPE OF INDEMNITY U BOND LI
OWNER'S INSURANCE WAIVER: I am aware that the Ucensee does net have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement. I
CHECK ONE ONLY: OWNER Q 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 c pliance ' Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Chris Briggs ,LICENSE#F2901 I SIGNAT RE
MP( JP 0 CORPORATION 0#3238 IPARTNERSHIPL# I LLC®# --1
COMPANY NAME Briggs&Heino Plumbing&Heating Co., Inc I ADDRESS IP.O• Box 538 I
CITY Centerville I STATE MA I ZIP 02632 1 TEL 508-778-0816 1
FAX 508-775-0404 I CELL Ir I EMAIL rbrjhj@aol.com
,
Mif
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
- :I
FEE: $ PERMIT#
PLAN REVIEW NOTES
1
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1
MAR. 1, 2016 8 :22AM1 HART INSURANCE NO. 917 P, 2
AC R CERTIFICATE OF LIABILITY INSURANCE _ DATE
A E(NIMI20 DNYYY 6 )
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 pertficate holder is an ADDmONAL INSURED,the pollcy(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 a COt7T'ACT Laura.1_ Murphy
HART INSURANCE AGENCY,INC. PHONEN'
243 MAIN STREET C.N Ems,. 508-759-7326 X207 FAXNoi:508-759-7388
PO BOX 700 E-MAIL s; ImurphyI hartinsuranceagency.Com
ADDRES
BUZZARDS BAY,MA 025320700 INSURERS)AFFORDING COVERAGE NAIC# _
', ,.` INsuRERA: ARBELLA PROTECTION INS CO 41380
INSURED Briggs&Heim Plumbing&Heating, Inc, INSDrRER e3. HARTFORD CASUALTY INS CO 29424
PO Box 53$
, • Centerville,MA 02632 IN3URERC:
INSURER D
LrNSURPRF: ....•
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 POUCIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. —
INSR IADDL SUER] I POLICY EFF POUcYEEP LTR, TYPE OF INSURANCE LIMITS_._. _ IN3D Yj T(l POLICY NUMOER (MM/DDrYYY� �D/YYYYi
A V ,COMMERCIAL GENERAL LIABILITY 9520049810 02/22/2016 02/22/2017 EACH OCCURRENCE'I$ 1,000,000
CL ''� PAMAGETO DENTED 300,000
AIMS-MADE 171 1 OCCUR PREMISES( a octurre,%) ,$ , _
MED EXP(Any one oorsan) S 5,000
PERSONAL$ACV INJURY $ 1,000,000
GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2.000,000
vr POLICY JECT I I LOC PRODUCTS•COMP/OF AGO $ 2,000,000
OTHER: 5
A AUTLOMOBILELIA5IUTY 1020008627 09/11/2015 09/11/2016 COMbINEDSINGLELISIff $ 1,000,000
ANY AUTO _ BODILY INJURY(Porporton) $
ALL OWNED - / SCHEDULED 'BODILY INJURY(Per strident) 3
NON-OWNED
Y NOTC/S PROPERTY DAMADDE
l/
1 HIRED AUTOS AUTOS J' Ui05 (Apr accident) S
A ' UMBRELLA LUAB 4600058318
�_ OCCUR j p2/22/2016 02/22/2017 EACH OCCURRENCE S 1,000,000
'.? EXCESSLI/AE CLAIMS-MA_0E AGGREGATE $ 1.000,000
�/DEO I RETENTIONS 5,000 ! 1$
g I WORKERS COMPENSATION 08WECRJ6614 02/22/2015 102/22/2017 I STATI,tr , ER
PER T} r
AND EMPLOYERS'Li ARILITY YIN
ANY PROPRIETOR/PARTNERt2XECL'TIVE EL EACH ACCIDENT 5 1,000,000
OFFICER/MEMBER EXCLUDED? Li
(Manoatory In NH) E L DISEASE-EA EMPLOYEE $ 1,000,000
:II/es.describe under — —
1 DESCRIPTION OF OPERATIONS beiO. E L DISEASE-POUCY LIMN ,S 1,000,000
DESCRIPTION OP OPERATIONS!LOCATIONS,I VEHICLES (ACORP lei,Additional Ronlarks Schedule,may I»ettac MO K morn space Is required)
CERTIFICATE HOLDER CANCELLATION
Fax#:(508)3AS-0836 -
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TOWN OF YARMOUTH THE EXPIRATION BATE THEREOF, NOTICE WILL BE DELIVERED IN
1146 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS.
South Yarmouth,MA 02664
AUTHORIZED REPRESENTATIVE
___ ,.'.'. I 77e#41,9,44
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