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HomeMy WebLinkAboutBLDP-21-005499 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Ei CITY YARMOUTH MA DATE 3/24/21 PERMIT# BLDP-21-005499 T" `yt JOBSITE ADDRESS 85 NANTUCKET AVE OWNER'S NAME adrian omalley P OWNER ADDRESS 167 ORCHARD RD EAST LONGMEADOW,MA 01028 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL al PRINT CLEARLY NEW: ❑ 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 DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 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❑ 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. 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 Kurt Pacini LICENSE 311041 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME KURT M PACINI ADDRESS 106 EMERALD ST CITY MEDFORD STATE MA ZIP 021552847 TEL FAX CELL EMAIL none ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • • • C(TY t � (X('tAC k MA DATE 7� /zcizl JOBSITE ADDRESS Nan 1-ut kes- Ike.- OWNER'S NAME /'/l GJL awedep, P OWNER ADDRESS --S644- 4 TEL6/7-2q O—WLFAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL idd' PRINT CLEARLY NEW:❑ RENOVATION:(REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑ FIXTURES 1 FLOOR-4 BSk 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 I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER /{Z- �I/la kyr INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO Er' IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY 0 BOND ❑. OWNER'S INSURANCE WAIVER:Iam 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 1/10'Gtr CHECK ONE ONLY: OWNER grAGENT ❑ SIGNATURE OF OWN R 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 pknnbirg wok and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# �(<0 i¢ I SIGNATURE MP❑ JP CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME ki)Q i \KA PAC\4( ADDRESS \3 \V ILE sr CITY VJO la.%)�Jk1 STATE1M* ZIP OI S U O . TEL-1 S l — q 7*—69$f FAX CELL EMAIL The Commonwealth of Massachusetts *: k� Department of Industrial Accidents 1 Congress Street,Suite 100 ce�cic &V Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: W.•- Lt ST City/State/Zip: V)e,irk 2u tM ago/ Phone#: `?$l .171/ -4/0$ Are you an employer?Cheek the appropriate box: Type of project(required): 1.01 ern a employer with employees(full and/or part-time).* 7. 0 New construction 2.[am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition I am a homeowner and will be10 ❑Building addition 4. 0hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12. r[ 1umbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractorsinsurance.;have employees and have workers'comp.insurance.; 13.�]Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MCI.c. 14.0 Other 152,§1(4).and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also 511 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: Policy#or Self-ins.Lie.#: Expiration Date: / Job Site Address: ' ncen/cicke- - City/StateJZip;.�Gt�I/N G(HCCU/'L c rieq Attach a copy of the workers'compensation policy declaration page(showing the policy number aid expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify the pains penalties of perjury that the information provided above is true and correct Signature: Date: f Phone#: i cc I - (0 o g y Official use only. Do not write in this area,to be completed by city or town officiaL 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#: