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Home My WebLink AboutBLDP-18-005055 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK «. CITY YARMOUTH MA DATE 3/15/18 PERMIT# BLDP-18-005055 Fg `�) JOBSITE ADDRESS 17 SHORE SIDE DR OWNER'S NAME PARMENTER HENRIETTA D LIFt-EST P OWNER ADDRESS 17 SHORE SIDE DR SOUTH YARMOUTH, MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YESE NO❑ FIXTURFS ' FLOORS—* 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 SYSTE _ 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 1 WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES❑ NO El 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. 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 Alex Braga LICENSE*5668 SIGNATURE MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ALEX B BRAGA ADDRESS 2 MOUNTWOOD RD CITY MARSTONS MLS STATE MA ZIP 026482111 TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE CI El DCD MIT FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =te= :"`�= CITY (�!NW�OtiT t1 MA. DATE ,3�Z�1/�( PERMIT# �6-40 "` ;..- JOBSIT ADDRESS sd()f , SC4,43-,:,;k2 lie OWNER'S NAME e' ll kv �f Cldac GOWNER ADDRESS: TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL' PRINT CLEARLY NEW: 0 RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ FIXUTRES Z FLOOR-. ' Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR I GRILLE 1 . LABORATORY COCKS i MAKEUP AIR UNIT --- r- t OVEN I -- POOL HEATER ROOM I SPACE HEATER MAR 2 a 2M$ ROOF TOP UNIT TEST \ii772,3i--,,,i-,:b-iw5-13--TARTm_Erti. UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 1 1 I I 1 1 1 1 1 1 III 1 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES A NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY ❑ OTHER TYPE 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 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 appli tion will be i complian with all Pertinent provision of the Massachusetts State Plumbing Code and Chaa ter 142 of the General Laws. PLUMBERIGASFITTERHAME: LPI CTG�I LICENSE# 3Oib SIG URE COMPANY NAME: h4Lt c&0 Pt ADDRESS: PO Ave y CITY: (G6(Q6,4‹ STATE: WA-- 0,�� = FAX: TEL: 17/-,57.36-45-745 _ CELL: __ ' EMAIL: biTKLi7c3 4 tai C6 MASTER 0 JOURNEYMAN IJ LP INSTALLER❑ CORPORATION El# `PARTNERSHIP 0# LLC 0# . _ The Commonwealth of Massachusetts ► ; h 1. Department of Industrial Accidents ;��= 1 Congress Street,Suite 100 €1,i_ 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 t Name (Business/Organization/Individual): van Aew / `t ii4/ 7L c-4 % Address: Po 6Ok 1 City/State/Zip: , GJ*t0I714/ PIA- ®�/ Phone#: 7 7 y-836--OS-7‘ Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction gam a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling y capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doingall work myself 9. El Demolition y [No workers'comp.insurance required.]t 10❑Building addition 4.❑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 11.1:Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑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. :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: 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 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 c ' under the pains and enalties of perjury that the information provided above is true and correct Si ature: Date: 2 4i Phone#: 7N-e56--or 76 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#: o'il SIN iIONMKALTH OF M i ACHUS Tfi DIVISION OF PROFESSIONAL LICENSURE BOARD OF PLUMBERS AND 'CASFI TTERS ISSUES Tr+E FOLLOWING LICENSE LICENSED AS A JOURNEYMAN PLUMBEI DA`J I€L J KNOWLTON iW P.O. B OX 406 ILALMOUTH MA 02541 ':/01/1. 2r 3); LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER MASSACHUSETTS DRIVER'S LICENSE ° ' 4a IRS 9a END 4d NUMBER •2014 NONE S92761945 tjr- DOB o i 30, 01s 02 83 1 1.SS 42 NEST 15 SEX M OM NONE KNOWLTON x 2 DANIEL J r 613 BOXBERRY HILL RD »87 =::64129