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Home My WebLink AboutBLDP-23-001204 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK e. va, -r CITY YARMOUTH MA DATE 9/6/22 PERMIT# BLDP-23-001204 kr, r' JOBSITE ADDRESS 248 CAMP ST UNIT B4 OWNER'S NAME MASSON DAVID L P OWNER ADDRESS 248 CAMP ST UNIT B4 WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING OTHER OTHER DESCRIPTION: 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❑ OTHER TYPE OF INDEMNITY 0 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 Andrew Mikita LICENSE 1i8843 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME ANDREW J MIKITA ADDRESS 48 INTERVALE LN CITY S HARWICH STATE MA ZIP 02661 TEL FAX CELL EMAIL none ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES S PERMIT# PLAN REVIEW NOTES • V• , .. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 4 = " E 1ATE D = i°- £tPl'ff W.VA-f ol4GC rk •MA DATE g'' -2O2 2— PERMIT# 2.3— /2 647 s ZP Q 20 A DR:SS 214gCAr'(Io sr.t fltT r3Li OWNER'S NAME L .16 G . dvtA SSO/l) BUI INGDERR, N RESS 246C4„1pSr -L liT i)L TEL 771-1-7Z2-099, FAx BY. CIJP - I YF't OK LW. PE � COMMERCIAL❑ EDUCATIONAL ❑ RESIDENT PRINT CLEARLY NEW:❑ RENOVATION:❑ -REPLACEMENTS PLANS S MITTED: YES❑ NO❑ FIXTURES 1 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 GASIOIUSAND 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 WATERHEATER ALL TYPES WATER PIPING OTHER - ESTIMATED VALUE OF WORK: I/52.65 I i I I i i I I. I I I I 1 1 1 - - 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 0 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 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 1i with Pertinent provisi of yie Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /• f( PLUMBER'S NAME A NIA Y T. Aldo T'9 LICENSE leggy..? 1GNATURE MP❑ JP Er CORPORATION 0# PARTNERSHIP❑# LLC❑# COMPANY NAME .fri 1 K//if} T�L/1 ADDRESS BO X C/8 . CITY 5 0 u7, 114 sit W I C I) STATE 4 ZIP duet TEL SO I 3 7 fole9' FAX CELL EMAIL • • • The Commonwealth of Massachusetts l��M=Mr ��!L Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individuai): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition • 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.111 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance? 13.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any 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. lam 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.Lk_#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and 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 under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: )?hone#: • Official use only. Do not write in this area,to be completed by city or town'offtcial City or Town: Permit/License# Issuing Authority(circle one): • I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: