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HomeMy WebLinkAboutBLDP-25-650 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK j CITY Yaf MoU 1/h� ~MA DATE )--- 7 c PERMIT#/ /3u� Z�-/p.�(j J JOBSITE ADDRESS /3 e a-�Tel- 6 '�' OWNER'S NAME(d,-oc F� a h 1e2- OWNER ADDRESS 5 ' Mc TEL / 0/..q4'.9$AX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL®- PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO IS. FIXTURES 0 FLOOR-0 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 INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER r'jdrc-Ato 4iZSh o2P i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL dh.;i42i:YES I2rr10❑' yy IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 1 O Q 2p25 {i UABILfiY INSURANCE POUCY OTHER TYPE OF INDEMNITY❑ BOND❑ \ \ SEA' y�J�7 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required t y Chit 42 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. -- CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 1 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 compsknce with all P rtinent provl' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,.J PLUMBER'S NAME LICENSE#��?5 rr GNATURE MP JP 3 itCORPORATION❑# PARTNERSHIP❑# LLC❑ n COMPANY NAME Y o q ( H et y P��iM 6 ADDRESS G t a 4 tic-I S I- on, CAI h C`T hcY1 h STATE h1 3 ZIP 0 - c TEL 1'O Cc(`�—7 00/ FAX CELL h f7 V G cf -7 00/ EMAIL Fa//(• lice�-y a� Y,trod • CO w' ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES COMMONWEALTH OF MASSACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE JOURNEYMAN PLUMBERcc PAUL T HEERY 64 LAUREL ST .____ W WHITMAN, MA 02382-2436 z 21358 05/01/2026 582938 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER COMMONWEALTH OF MASSACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE ' BOARD OF FI.UMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE MASTER PLUMBER • PAUL T HEERY `3 64 LAUREL ST WHITMAN, MA 02382-2436 cn J 11762 05/01/2026 582936 -- • LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER DATE(MM/DDIYYYY) ACCPREP® CERTIFICATE OF LIABILITY INSURANCE 9/2/2025 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 have ADDITIONAL INSURED provisions or 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: Kyle Austin Austin Insurance Agency, Inc. PHONE FAX 316 Washington St, Und 1 ukic-No.Ext):781-447-5561 (Ivc.Not 781-447-1246 Norwell MA 02061-1780 ADDRESS: Service@myinsuranceman.com INSURER(S)AFFORDING COVERAGE NAIC# License#:3686821 INSURER A: Progressive 25656 INSURED PAULHEE-01 INSURER B Paul T Heery DBA Heery Plumbing And Heating 64 Laurel St. INSURERC: Whitman MA 02382 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1927683505 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. INSR ADDL SUBR 7,i POLICY EFF POLICY EXP LTR TYPEOFINSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MMIDDtYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY N N PGR973036865 2/1/2025 2/1/2026 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $50,E MED EXP(Any one person) $10,000 PERSONAL 8 ADV INJURY $Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO- X POLICY JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PPERTUTE I I OTH AND EMPLOYERS'LIABILITY Y/NER ANYPROPRIETOR/PARTNER/EXECUTIVE EL.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Description of Operations: Plumber and Heating systems Location Insured:64 Laurel St.,Whitman Ma 02382-2436 Certificate holder is listed as Additional Insured on a Primary&Non-Contributory basis including a Waiver of Subrogation BUT ONLY if there is a written contract between Paul T Heery and Certificate Holder requiring these terms. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth AUTHORIZED REPRES NTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD