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Home My WebLink AboutBLDP-25-736 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t=fir' II CITY '(k YIOvr+(' MA DATE 9 A- - Z� PERMIT $LD7.j-3.) r-� JOBSITE ADDRESS 2 ��1- A'i' u F c OWNER'S NAME I-6 N Z 1 OWNER ADDRESS 7 B42IA•NNA wRY DRAGir mP TELq S y-7 50 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL$ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:g PLANS SUBMITTED:YES❑ NO El FIXTURES 3 FLOOR— 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 I DRINKING FOUNTAIN I FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK R F TOILET URINAL c� WASHING MACHINE CONNECTION SF ,7 n 1015 WATER HEATER ALL TYPES _ WATER PIPING OTHER UNA INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 5:1 OTHER TYPE OF INDEMNITY❑ BOND 0 OWNER'S INSURANCE WANER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER® AGENT❑ SI OF OWNER OR AGENT I hereby ce' at 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �j PLUMBER'S NAME I PN $IreTkN MkG4-4 LICENSE#1'13a SIGNAT MP] JP❑ CORPORATION❑# PARTNERSHIP❑# LLC 9350 COMPANY NAME(PSYkt, YV GARN IGA1i ADDRESS 2 2- 1441.117e oFrf.f CITY STATE rm- ZIP 074(1 4' TEL COd �—g i 41 FAX CELL EMAIL Kt Gt A @ cc45+af p he CCM ACORDDATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 12/30/2024 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 Tina Reeves NAME: The Hilb GroupNew England,LLC PHONE (800)640-1620 FAX g INC No,Ext): (A/C,No): dba Dowling&O'Neil ADDRESS: treeves@hilbgroup.com 973 lyannough Road INSURER(S)AFFORDING COVERAGE NAIC a Hyannis MA 02601 INSURER A: Property&Casualty Insurance Co of Hartford 34690 INSURED INSURER B: Arbella Protection Insurance Co 41360 Coastal Plumbing&Heating LLC INSURER C: Hartford Underwriters Insurance Co 30104 22 Whites Path INSURER D: Westchester Surplus Lines Ins 10172 INSURER E: South Yarmouth MA 026£4-1212 INSURER F: COVERAGES CERTIFICATE NUMBER: 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. NOR I ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WV() MI POLICY NUMBER (MDD/YYYY) (MWDD/YYYY) 1,000,000 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE RENTtD CLAIMS-MADE X1 OCCUR PREMISESO(Ea occurrence) $ 1.000,000 MED EXP(Any one person) $ 10'000 A 08SBABL9LIS 12/31/2024 12/31/2025 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 HX POLICY n PRO- 2.000.000 JECT LOC PRODUCTS-COMP/OP AGG S OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B 1—' OWNED N/ SCHEDULED 1020153682 12/31/2024 12/31/2025 BODILY INJURY(Per accident) $ _ AUTOS ONLY /2 AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) X UMBRELLALIAH X OCCUR EACH OCCURRENCE $ 2,000,000 A — EXCESS UAB CLAIMS-MADE O8SBABL9L1S 12/31/2024 12/31/2025 AGGREGATE $ 2,000,000 DED X'RE'rENTION$ 10'000 I $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N X ST TOTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE N NIA OBWECBC2X9T 12/31/2024 12/31/2025 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE•EA EMPLOYEE $ 1.000,000 II yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT f EACH POL CONDITION $500.000 POLLUTION LIABILITY D G74289587003 08/25/2024 08/25/2025 AGGREGATE $500,000 1 DEDUCTIBLE $2.500 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be itlached it more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements.Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended thecoverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 114E Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 _ ::-~ -_ C 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • The Commonwealth of Massachusetts Department of Industrial Accidents ! _s_ Office of Investigations ette La f Y a City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): Coastal Mechanical Address:22 Whites Path City/State/Zip: South Yarmouth, MA 02664 Phone #: 508-737-8747 Are you an employer? Check the appropriate box: Type of project(required): 1.Q I am a employer with 40 4. ❑ I am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. El New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers P h'. 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its l0.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no WATER HEATER employees. [No workers' 13.1X] Other comp. insurance required.] "Any applicant that checks box it I 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: Hartford Underwriters Insurance Company Policy#or Self-ins. Lic. #:08WECBC2X9T Expiration Date: 12/31/2024 Job Site Address: 2 RAILWAY BLUFFS City/State/Zip: WEST YARMOUTH 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 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: /t & - Date: 09/30/25 Phone#: 508-737-8747 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❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 50lumbing Inspector 6.DOther Contact Person: Phone#: