The URL can be used to link to this page

Home My WebLink AboutBLDP&G-19-07192 I �, rtiv � CITY/TOWN L4I 41 MA DATE /� • • �_Y):1=fie —�--�,•- ' t.�,'�'1 PERMIT#� Q�� 71� , JOBSITE ADDRESS :�3 R,Yl.t 12 . O(V S AME GL)q_zia-Q tiv OWNER ADDRESS TEC" FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL X PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ FIXTURES T FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE • DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM • DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET _ URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES t WATER PIPING - OTHER • INSURANCE COVERAGE: y� 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 ❑ 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 In compliance with all Peril vision o e Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Tl YQO J LICENSE It 5 ct 3 IGI RE MP JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME T w CiecM/t."a. ltcdLC ADDRESS TO C 41,b�1R YL1,� H40vvwet. i CITY g0.A5 OtAY✓470-t.-- STATEIM- ZIP C `a•-' L0 ( TEL C600 3(3 -5 c FAX CELL EMAILTI mac{Ilya SLR 'n �YY-1�1� C1z1� . • 7 • (g . \ The Commonwealth of Massachusetts (i 4 Department of Industrial Accidents =? '� 0 1 Congress Street,Suite 100 3 13oston MA 02119-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITI-I THE PERMITTING AUTI-IORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip:. .. Phone#. Are you no employer?Check the appropriate box: Type.of project(required): 1.0 I am a employer with • _employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Ej Remodeling any capacity.[No workers'comp.insurance.required.] • 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10[]Building addition 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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.nR0of repairs These sub-contractors have employees and have workers'comp.inaurance.1 6.❑We area corporation and its officers have exercised their right of exemption per MGL c, 14.❑Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box III must also fill out the section below showing their workers'compensation policy information. 1 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: • Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration elate). 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: Phone#: 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other • Contact Person: Phone#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . ;,.la't CITY �T-�G3/j,Yy.d..�I,.-� '1--_-- _-__I MA DATE : PERMIT# /y /�`/� '�� JOBSITE ADDRESS 'J� _ alt_ r,Da- �_:OWNER'S NAVE -- __ OWNER ADDRESS -- --- .---. ----- ------- -- TEL '��Z-'� _.;F -- - - i TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL I RESIDENTIAL IX PRINT CLEARLY NEW:)___II RENOVATION: _-_ REPLACEMENT:!-I PLANS SUBMITTED: YES[I NO® APPLIANCES 1 FL,(JORS--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 • BOILER . --- r illili. -J --1 -----I}----.-I_- I' _ ; ___-J iiii-_1L I__-__.I BOOSTER . 1111.-_--- MI .- -J ----= ____I -----1 NM -I NI_ I I CONVERSION BURNER _--_1 PIM Mg® __._.' ___I_-J I I®MO.___-' -__ COOK STOVE _ .._J L _ }.L--JI ._II—J I— •TJ---J ____ ---I= i DIRECT VENT HEATER __.__I ' j® -. -I__ I ! 1 _I I I _____ I DRYER 1 ____I - I --- = ' -J -----J ��--�_-!=-- FIREPLACE • ____IMN .; __.._ .. . - ` FRYOLATOR • I-----I IME®Mai= -- --i - ' - _i J I_____ II= ----I __I 1 FURNACE ®MI 1 I-J 7_1 1I_..__.II -_�' MI __ I -JI _____1]_ I GENERATOR - -+ 1 I_....._._Ij___..--;1.....J(I - i ----.-I --- .._I:= _j=._ J---.1 I GRILLE _.-.__I®__J® _—1.®_ __J ! E_ (—_[-j- . . •I INFRARED HEATER - __I ..----._!MI MI - WWI -_-J i A _.-i . LABORATORY COCKS ___I!-..-___J NMI® _--__.I®,— ____J - i ---` ---__-_-. ,NNW ._1 MAKEUP AIR UNIT OVEN I 1MIMLR --_--ice .. ..J' ` -1NM I I POOL HEATER __J J[-__I _—!( .---- la.___I_---f L - I�I = - I ROOM/SPACE HEATER ---A-_. _I ---`JIM 7711 ER® J _7_71-----..' ----! _...-.I C - J • ROOF TOP UNIT -.__-_I I®Iiii ____. _.--_._` ; MN____ I}_._-' __ 1._____A i TEST 1_--_I®NMI '•_MI---•-- - =, - I I-- 1 I UNIT HEATER --.- = _ =®____-! -1[ I_---_; -_-i UNVENTED ROOM HEATER __.__ 717.1.l .._...__i 1 _ 1 - ..._;1_ _ ' _._. :. ._.-1 ____-1 I-_ f WATER HEATER 111111=®ININIE .._. - •MN -- 1 ---•'NMI I______I ISIIIRMIIMI --- OTHER i I i • .. .._._i _ __I - -....... _... .-I}----I_____Jr ---1---- ---- 1---- 1( _1 -i I ! • )INSURANCE COVERAGE . - I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES X NO D I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X OTHER TYPE INDEMNITY ._1 BOND LA 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 DI 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 P - ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMETtng i LICENSE# 5 RE MP C411 MGF_I JP Li JGF.i LPG!L_JI CORPORATION I __}# - 1 PARTNERSHIP I_ I#_______________I LLC,-i#________ t COMPANY NAME:I_ (ci NA SS rjl2p n,. i2 4 fpJ CITY gi,(--- STATE JV4f7r.1 ZIP_02,15Lo-,j__1TEL1 • • - i = 5�S 1 FAX +-- - - CELL -- - •- - EMAIL_ Vh_eL--e_42_- -�j--a_ -k'RV Rs �:C..a �1 all- . '4 {�