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Home My WebLink AboutBLDP-25-1010 4gCc i$o(01✓i1'( � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WOf kk CITY 1 ‘, MA DATE /al 3 a s' PERMIT# �70I�Z.5:10/O w ;liry JOBSITE ADDRESS Y f /0'".2® OWNER'S NAME fe/Att.Fi/.iv`lei OWNER ADDRESS ff 02 6" TEL"7" TEL 5 Og gGA y0/0 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:® PLANS SUBMITTED:YES❑ NOS] FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 B 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 -R E SERVICE I MOP SINK — /f0 I TOILET _ 11� I 4 Y4 URINAL _WASHING MACHINE CONNECTION DL ILDIHy!!SME#� WATER HEATER ALL TYPES a� _ WATER PIPING OTHER I _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ❑ BOND 0 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 LU 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. 6 �j PLUMBER'S NAME ,OfviL /34CCGJ LICENSE#/ iq , /J SIGNATURE MP® JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME s� 1 i'/).). ADDRESS 97 Gi -ft Sj CITY 7;4/4/t f/e 4, STATE/'4 ZIP®.21 TEL TEL (/7 822 r'3�/ FAX SSW 9 Y7 a 7Y CELL EMAIL l'/4CCt,Setf,4 eayg oo. Cni7r ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT It PLAN REVIEW NOTES ne t-ammunweuttn o,/jrlussucnuseus Department of Industrial Accidents Office of Investigations f-_Ft c Lafayette 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): J '/t 'frdp /Meo%iF4ie� Address: 97 by c'S 3 S City/State/Zip: /y7/4.6/le hie, 4 2//- oakir Phone#: l'7,2 o xf, Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑lam general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers'comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.®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 employees.[No workers' 13.0 Other comp.insurance required.] 'Any applicant that checks bor.#1 must also fill out the section below showing their workers'compensation policy information. 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 anployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 'am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nformation. nsurance Company Name: r. 'olicy#or Self-ins.Lic.#: Expiration Date: ob Site Address: TABLE City/State/Zip: Mach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of tvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct gnature: Date: /2 .-s tone#: 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): 110Board of Health 20 Building Department 31:City/fownClerk 4.0 Electrical Inspector 5E'lumbing Inspector 6.0Other- inrormauuii Wall u low..�v."ALA N. Massachusetts GeneralP Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, employee is defined as "...every person in the service of another under any contract of hire, an express or implied, oral or written." AnP Y em to er is defined as "an individual, partnership, association, corporation or other legal entity, or any two the legal representatives of a deceased employer, oor�more a of the foregoing engaged in a joint enterprise, and including g legal employing employees. However the receiver or trustee of an individual, partnership, association or otherentity, owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the mP ma dwelling house of another who employs persons to dointenance, construction or repair work on such dwelling house p to the grounds or building appurtenant thereto shall not because of such employment ent be deemed to be an employer. er. or on §25C 6 MGL chapter 152, also states that "every state or local licensing agency shall withhold the issuance or ( ) renewal ofa or permit license to operate a business or to construct buildings in the commonwealth for any produced who has not acceptable evidence of compliance with the insurance coverage required." 152, Additionally, MGL chapter §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance , requirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers' p compensation affidavit completely, by checking the boxes that apply to your situation and, if sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of necessary, supply insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than thedoes have members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP a policyis required. Be advised that this affidavit may be submitted to the Department of Industrial should employees, q The Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. affidavitof returned to the cityor town that the application for the permit or license is being requested, not the Department be Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' Industrial should enter their compensation policy, please call the Department at the number listed below. Self-insured companies p self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit yo u ou to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submitmultiplepermit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture ( i.e. a doglicense or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Invest igations ations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 021 l l-17 50 Tel. (617) 727-4900 or l-877-MASSAFE Fax (617) 727--7749 '7 1A 1 Ch a COMMONWEALTH OF MASSACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE MASTER PLUMBER DAVID W BACCUS 97 WEST ST MIDDLEBORO,MA 02346-1942 12896 05/01/2026 595265 BUILDING DEPT DEC 3 0 2025 TOWN OF BARNSTABLE