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Home My WebLink AboutBLDP-21-004462 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK E, _I4r. CITY YARMOUTH MA DATE 2/5/21 PERMIT# BLDP-21-004462 _S JOBSITE ADDRESS 171 LONG POND DR OWNER'S NAME LONG LEONARD T P OWNER ADDRESS 147 SUNSET STRIP MASHPEE,MA 02649 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES FLOORS BSM 1 2 3 4 5 _ 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE , DEDICATED SPECIAL WASTE SYSTEM 1 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 WATER PIPING OTHER 1 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 ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El 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 Matthew Hyland LICENSE776 SIGNATURE MP ElJP ElCORPORATION El# r PARTNERSHIP ❑# LLC ❑# COMPANY NAME [NATTHEW HYLAND ADDRESS 127 COPELAND ST CITY BROCKTON STATE MA I ZIP 023016958 TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES • Yes No THIS APPLICATION SERVE AS THE PERMIT FEESS PERMIT# PLAN REVIEW NOTES ., ; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK G a _: ! CITY PERMIT# ► .DP 2,1'u `t'�2' F7.I,. �c�..t'N 1vQ,,,w� .__ . MA DATE / a( JOBSITE ADDRESS L _ OWNER'S NAME 4 r I 7� _ �� II-� _, _, ,. .� . Nh Dt,JS I o,�fr� _. POWNER ADDRESS TELS0r 67q- 7,jci I 1FAX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL a PRINT '` � CLEARLY NEW: RENOVATION: REPLACEMENT:Lcif PLANS SUBMITTED: YES NO „--- FIXTURES 7 FLOORS 4 6 7 9 10 11 14 BATHTUB111111S1CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM f, �I �- DEDICATED GASIOIUSAND SYSTEM I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM �_ ---1111111. �—__— DISHWASHER 111111111111111111-1111.111111111111111111111111111111.1 DRINKING FOUNTAIN111111111111111111. _-11111111111 :_ IIIII FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) , . KITCHEN SINK LAVATORY IOW= MIEN all-- -.Rill ROOF DRAIN SHOWER STALL SERVICE l MOP SINK TOILET I w }_ URINAL �� WASHING MACHINE CONNECTION 111111111111®_ 1111111 WATER HEATER ALL TYPES MIME ,. wo,o �I ,, '. WATER PIPING __ 1 - N __ 'I0.11_1111111 ,11m111u1111-i1s1111I . . OTHER i C, OJ Q(A ia.,, , ,., ;_______ , __, . ._ _ 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 CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V 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 a a rate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli h all Pertinent provision of the Massachusetts State Plumbing C ode and Chapter 142 of the General Laws. PLUMBER'S NAME 'MBA ,.& \k,til, ,LICENSE# 177 /' SIGNATURE MPL �JP ' CORPORATION #' PARTNERSHIP # �_ ILLC #1 1 COMPANY NAME[ By0A6 kite— _J ADDRESS 3J Co. % (e CITY ,„,,,,,,pit STATE ,_„) ZIP Q2J6 e i TEL 7 7 q'S01'7 6 i FAX CELL. _1EMAIL A1NQ .fivhcQ, 6M (C-COv t. ._ ._ _ __ --- he Commonwealth of Massachusetts t— Department of Industrial Accidents Office of Investigations Lafayette City Center j 4_i;F;° 2 Avenue de Lafayette,Boston,MA 02111-1750 := www mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information llY/ Please Print Legibly Business/Organization Name: Address: L'C7 Co/Lc /triL City/State/Zip: , bec'K 0,;69 Phone#: 7?q-S 2//' 7 S% Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. 0 Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.g I am a sole proprietor or partnership and have no 7. El Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers' comp.insurance required]* ' 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.gr Other kw *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic.# Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,u e ains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 7711- /-74'6 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): 1 f Board of Health 2.D Building Department 30 City/Town Clerk 4.DLicensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia TE ACORDSW - CERTIFICATE OF LIABILITY INSURANCE DA01/21/2021Y) PRODUCER ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION O'ROURKE INSURANCE AGENCY,INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 8 SOUTH AVE WHITMAN,MA 02382 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 781 447 7375 FAX:781 447 9118 EMAIL: orourkeins@aol.com INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A' NAUTILUS Matthew Hyland INSURER B: 127 Copeland St INSURER C Brockton,MA 02301 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'. POLICY EFFECTIVE POLICY EXPIRATION LTR INSR) TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE IMM/OD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 NN1207423 01/14/21 01/14/22 UAMAIJ TO RENTED $ 100,00 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurence) CLAIMS MADE n OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,000 - GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 7 POLICY n PEO n LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ -I OCCUR ri CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND yyl.SLAIU ER TORY LIMITS ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS PLUMBING AND HVAC OF RESIDENTIAL OR DOMESTIC DWELLINGS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN CITY OF FALL RIVER NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL ATTN:PLUMBING INSPECTOR 160VENMENT CTR IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR FALL RIVER,MA 02722 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE JENNIFER LOWE ACORD 25(2001/08) ACORD CORPORATION 19e :COMMONWEALTH OF MASS.ACHUSETTS, DIVISION OF PROFESSIONAL LICENSURE PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE JOURNEYMAN PLUMBER MATTHEW HYLAND z 127 COPELAND ST BROCKTON, MA 02301-6958ILI U 33776 05/01/2022 868279 -► i it 5WaFrig' ' i' = = 1 11 CONTROL # J01474905 IMPORTANT If your license is lost, damaged or destroyed; is inaccurate; or needs to be corrected, visit our web site at mass.gov/dpl for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. This license is subject to Massachusetts General Laws and • regulations. Your license is a privilege, and cannot be lent or assigned to any person or entity under penalty of law. Keep this license on your person or posted as required by law and/or regulations. ii