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HomeMy WebLinkAboutBLDP-26-46 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY/TOWN SOLD h Va iraL- I^MA DATE ///4/4 [� PERMIT 24--`�- ()ell() JOBSITEADDRESS a/� of 1� V ell '!(j' ReA OWNER'S NAME KC( r'et/r PIooc'de POWNER ADDRESS 2 '2 K U s TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT • CLEARLY NEW:El. RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES Z FLOOR-0 I BSM 1 2 3 j 4 I 5 I 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE j DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM j DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM i DISHWASHER I I DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN I i SHOWER STALL SERVICE/MOP SINK j T , I RECEIVED TOILET I I URINAL .),6t4 14 2026 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES / r WATER PIPING / I j I BUILDING DEPARTMENT OTHER f i By — - j � 1 j i i • I I 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. CHECK ONE ONLY: OWNER 0 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 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 corn I. all Pe ovision of the Massachusetts State Plumbing Code and C apter 142 of the General Laws. PLUMBER'S NAME � ` Ychr LICENSE# I/308 SIGNATURE MP1,0 JP❑ CORPORATION -0 c2)atIC PARTNERSHIP❑# J LLC❑# COMPANY NAME L �J yon3 a(NibiI E Haiti+�i _ ADDRESS 632 CG,MbrrdJJCe 517 CITY ((AA.esfd r STATE Met/et ZIP V l /G TEL 50g`868`376i FAX CELL 774-/_ / 'O16 EMAIL ST(.l(.1eriC)L•yon5 PHe COr'- /YYY ACGRD CERTIFICATE OF LIABILITY INSURANCE DATE /14 o2D n 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 NAME; Joanne Augustine Herlihy Insurance Group PHONE FAX 51 Pullman Street (AIc.No.Ear.508-756-5159 (NC,No):508-751-5747 Worcester MA 01606 ADDRESS: certificates©herlihygroup.com INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:Arbella Mutual Insurance Company INSURED LYONPLU-01 INSURER B Lyons Plumbing&Heating, Inc. 632 Cambridge Street INSURER C: Worcester MA 01610 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:805128730 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP UNITSLTR INSD WVD POLICY NUMBER ,(MMIDD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY Y Y 8520149016 10/8/2025 10/8/2026 EACH OCCURRENCE $1,000,000 DAMAGE RENTED CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEM_AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X JECT LOC PRODUCTS•COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y 1020148957 10/8/2025 10/8/2026 CaOMBINEDacddenq SINGLE LIMIT $1,000,000 (E ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _AUTOS ONLY (Per accident) A X UMBRELLA LIAB X OCCUR V V 4620149018 10/8/2025 10/8/2026 EACH OCCURRENCE $5,000,000 EXCESS_IAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$1n,nn $ A WORKERS COMPENSATION V '4220148911 10/8/2025 10/8/2026 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNERIEXECUTIVE N N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? -_-- - --- ---- (Mandatory in NH) • E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If mom space Is required) Subject to policy terms,forms and conditions.Certificate holder,and any person or organization requested,is included as an Additional Insured on a primary and non-contributory basis as required by a written contract,and Completed Operations on the General Liability Policy.A Waiver of Subrogation applies on the General Liability,Automobile Liability,and Worker's Compensation when required by written contract.Excess Liability is follow form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 114E Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 fY} ..L, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations s =10= Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 ,27 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Lyons Plumbing& Heating Inc. Address:632 Cambridge Street City/State/Zip:Worcester/MA/01610 Phone#:774-314-0466 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 15 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anycapacity. employees and have workers' P tY 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof r4 ..Q\.q airs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.�Other t. comp. insurance required.] *My applicant that checks box#1 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:Arbella Mutual Insurance Company Policy#or Self-ins. Lic.#:4220148911 Expiration Date: 10/08/2025 Job Site Address: 2 o U I°h V S City/State/Zip: gpick.‘yei ,d,y} A-O2 ihy 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: Date: /f �6 Phone#: 508-868-3761 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): 10Board of Health 21:1 Building Department 31:City/Town Clerk 4.❑Electrical Inspector 5E1Plumbing Inspector 6.0Other Contact Person: Phone#: _.__.___.______..___ V COMM. WEALTH OF MASSACHUSETTS CONTROL# J 2 2 31,0 7 3 DIVISION OF OCCUPATIONAL LICENSURE BOARD OF IMPORTANT PLUMBERS AND GASFITTERS If your license is lost,damaged or destroyed;is inaccurate;or ISSUES THE FOLLOWING LICENSE a needs to be corrected,visit our web site at mass.gov/dpl MASTER PLUMBER for instructions to ensure the proper mailing of your Renewal z Application and any other correspondence. DAVID P LYONS g m 632 CAMBRIDGE ST W This license is subject to Massachusetts General Laws and n regulations.Your license is a privilege,and cannot be lent or WORCESTER,MA 01610-2632 2 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. 11308 05/0112026 601331 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER