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HomeMy WebLinkAboutBLDP&G-22-002861 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w, CITY YARMOUTH MA DATE 11/17/21 PERMIT# BLDP-22-002861 JOBSITE ADDRESS 49 MONOMOY RD OWNERS NAME Cynthia Morton P OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES El NO❑ FIXTURES FLOORS-. RSM 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 El 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 El BOND El 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 at of the details and Information 1 have submitted or entered regarding this application are true and accurate to the best of my knowledge and that an plumbing work and Installations performed under the permit issued for this application will be in compliance with at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME John Kane LICENSE X755 SIGNATURE MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME JOHN KANE ADDRESS 39 MONOMOY RD CITY IS YARMOUTH STATE MA ZIP 026641984 1 TEL FAX CELL I EMAIL Isjk1725@gmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES P /° c / MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 17g 7 CITY tn MA DATE t 4 - 1 i 1 PERMIT# JOBSITE ADDRESS . ' , yt k1 (7 OWNER'S NAME Cy rn ;"mot i'1" • pOWNER ADDRESS TEL 6.0 81 " 360 -d S.'7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL t.<J PRINT CLEARLY NEW: [ RENOVATION: REPLACEMENT: ( PLANS SUBMITTED: YES ❑ NO P FIXTURES -1 FLOOR-I 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/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 R E ROOF DRAIN SHOWER STALL1 NOV 1 2 8 SERVICE I MOP SINK I TOILET L URINAL BL ILDIN( L) }'AR I MEN [ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING _ OTHER INSURANCE COVERAGE: I have a current liabilitinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES x❑ NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [I 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 complian with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. •1/(..."—‘,, PLUMBER'S NAME LICENSE #12,7 ) SIGNATURE • MP ❑ JP CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME f\tin C K6. 1 i rU C 4 r n J ADDRESS 3 9 and i`i /k7 z CITY , ` �/A 1'"rl'LO ti h STATE vr1<-,, _ ZIP C: ( c/ TEL FAX CELL S O _��'_� - .ti E SY4 EMAIL .J � 4 " C { � X i H Co C0 The Commonwealth of Maisachusetts lA=cki_C/ Department oflndustrialAecidents MOBa • 1 Congress Street,Suite 100 • —t: Boston,MA 02114-2017 am, www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Phimbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ' Applicant Information Please Print Legibly • Name(Business/Organization/Individual): • Address: 'City/State/Zip:. Phone#: Are you an employer?Cheek the appropriate boo: Type of project(required): LQ 1 am a employer with employees(full and/nr pan-time).' 7. ❑New construction 2.0 t am a sole proprietor or partnership and have no empluyeea working forme in I. El 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 10 Q Building addition 4.❑1 am a homeowner and will be hiring contactors to conduct all wok on my property.I will ensure that all contractors either have workers'compensation insurance or am sole 11.E Electrical repairs or additions proprietors with no employers. 12.E Plumbing repairs or additions 5.1=I Ian:a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contactors have employees and have workers'comp.insurance • 6.0 We area corporation and its officers have exercised their right of exemption per MGL a 14.Q 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 him outside contractors must submit a new affidavit Indicating such. tContractors that check this box must attached tin additional sheet showing the name of the subcontractors and state whether or not those entities hare employees.If the subcontractors have employees,they must provide their workers'comp.policy number. .. I am an employer that is providing workers'compensatibri Insurance far 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 fins 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 ofperjury that theinformation provided above is true and correct. Signature: Date: Phone#: Official use only.Do not write in Ads 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#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1-1,*f L CITY YARMOUTH MA DATE November 17, 202' PERMIT# BLDP-22-002861 JOBSITE ADDRESS 49 MONOMOY RD OWNER'S NAME Cynthia Morton G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS --> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN o POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST 4. UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER i. 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 ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKIN3 THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER 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-GASFITTER NAME John Kane LICENSE # 22755 SIGNATURE MP ❑ MGF ❑ JP 0 JGF ❑ LPG! ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC 0 # COMPANY NAME: EJOHN KANE ADDRESS. 39 MONOMOY RD, CITY S YARMOUTH STATE MA ZIP 026641984 TEL FAX ] CELL EMAIL sjk1725 a(7,grnail,com S31ON M3IA0:I NVId #1IVH9d $:333 ❑ 11W2,13d 3H1 SV S3AH3S NOI1VOIlddV SI1-11 ON SOA S31ON NO1103dSNI IVNId AINO 3Sfl b0103dSNI HO 3OVd SIH. S310N NOI103dSNI SVJ H000N 64. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,,— CITY( y•Gtv �v► v u h,.�����,� S- MA DATE 1 i ' l 1 ' dZ t PERMIT JOBSITE ADDRESS q ill J ''‘ d ' OWNER'S NAME C i1\ v ri-0 OWNER ADDRESS 5a ✓nc TEL Bog 3(0 0 0 S-Isf 7 FAX T { OR � T OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL Xc PRIN CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: IA PLANS SUBMITTED: YES ❑ NO a APPLIANCES FLOORS-4 BSIO 1 2 3 1 5 6 7 8 9 10 11 12 BOILERBOOSTER —� CONVERSION BURNER COOK STOVE DIRECT VENT HEATER i DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT I, OVEN POOL HEATER ROOM ; SPACE HEATER R " C ° r ROOF TOP UNIT MINIM I� TEST UNIT HEATER _. . . ' ' � 11NVENTED ROOM HEATER _. WATER HEATER �u i� ��- OTHER 1 � � I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of 'MU.. Ch. 142 YES © NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND C 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 applicationwaives- this requirement. CHECK ONE ONLY: OWNER ❑ AGENT E1 SIGNATURE OF OWNER OR AGENT ‘i-s 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 complianc with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter '142 of the General Laws, PLUMBER-GASFITTER, NAME LICENSE # Zti�5 SIGNATURE MP ❑ MGF ❑ JP ( JGF E LPGI ❑ CORPORATION ❑ #f PARTNERSHIP ❑ # LLC ❑ COMPANY NAME . rtc Kati .1e ac1 in C9 ADDRESS 3 9 1fc4 r o . el -- CITY 5- reh STATE lir A ZIP 0 az h 6 4 TEL 5-6 &' -(D S- s - bS FAX CELL EMAIL j Ia III t & L/ COQ h o o . CO tr ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes N THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT PLAN REVIEW NOTES