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Home My WebLink AboutBLDP-21-004861 <‹ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ``�,�Q4►tf CITY_ Yarmouth MA DATE ....,._..._2/23/2021 PERMIT# g Z fl P-1 17001-1W, JOBSITE ADDRESS 19 Lavender Lane OWNER'S NAME Co. POWNER ADDRESS 19 Lavender Lane West Yarmouth TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL p4/ PRINT �/ CLEARLY NEW:Lb RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR--, BSM 1 2 3 4 5 0 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 I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK - LAVATORY -- ------ ------ -- ------ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 1 WATER HEATER ALL TYPES __ WATER PIPING OTHER INSURANCE COVERAGE: �/ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142. YES pQ 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 arc true and accurate[o e best of my knowledge and that all plumbing work and installations performed tinder the permit Issued for[his application will be in compliance with al e • ent ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws PLUMBERS NAME Spencer Hallett LI DENSE 1t 16224 MP[l JP❑ CORPORATION❑it PARTNERSHIP❑# LLC❑# COMPANY NAME Spencer Hallett Plumbing-and Heating _ ADDRESS 361 Old Falmouth Rd Unit 36 CITY Marstons Mills STATE NIA ZIP 02648 TEL 50.8-428-6080_ FAX.508-428-7991 CELL EMAIL spencer@@hallettplflmbing.com ��f� �\ . •• i ♦ .._ .J -_____. • ....,.7. Department of.ndusfria!Accidents =''i Zt Office of Irrvestigm omc• i -_=� ; �, 600 Washington Street (Wilit= • • Boston,.t Me4.0.M • • .,4,.;' www.mass.gov/cha• Workers' Corapensation Insurance A ZdayibBtulders/ContractorslEIect icians/Plumbets Applicant Information Please PzintLegibly• 'Name csncss/orga ndividna1): Spencer Hallett Plumbing and Heating Address: ' 381 Old Falmouth Road, Suite 36 • City/State/Zip: Marstons Mills, MA 02648 phoned 508-428-6080 Are you an employer?Cheek the appropriate boat ' Type of project(required): .1.El I am a employer with 11 4. []I am a general ctmtractor and I employees(HI and/or part-time).* have hired the sub-contractors 6, D New construction 2. I am a sole proprietor or partner- These on the attached sheet 7. [1 Remodeling ship and have no employees Tb ese sub-coutracinrs have $. []Demolition • • working forme in any capacity. employees and have workers' coin insurances 9. El'Building addition • [No workers'comp.insurance I'• • wed:1 5. ❑ We area corporation and its 11E]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E Plumbing repairs or additions myself [No wadi-ers'comp t of exemption per MGL 12 fl Roof repairs insurance r &j t c.152,§1(4),and we have no employees.[No workers' 13.D Oilier cozup,insurance required.] *Any applicantthB1chk box#1 aunt ]so fill outdmccaddie scction below slicriving their workers'compensation.policy infonaation. t Homeowners who submit this affidavit indicating they axe doing all work and lima hire outside contractors must submit anew adavit indirasing suck tContractors tbat cheek this box most attached an additional sheet showing the namc of the sob•amisachus and state whethernr not those,.,atities hags • employas.Tf the sub-contractors have aaployces,they most provide their world.;comp.policy rmmbcr. M1 i can an employer that is providing workers'compensation insurance for my employees. Below is the poky and job site information. Insurance Company Name: The Hartford 08 WEC AE8RGA Expiration Date: 2/22/2022 Policy#or Self-ins.Tic.#: �� • Job Site Address: 19 Lavender Lane city/sty: West Yarmouth, MA 02673 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c,152 can lead to the imposition of criminal penalties of a fine tap 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 tbvt 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 th and penalties ofperjury that the information provided above rstrue and correct Signature: ,,.� Date: 2/23/2021 iI Phone#: 508- 8- 080 • Official use only. ,Do not write in this area,to be completed by city or town ofciaL .: 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#: •