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Home My WebLink AboutBLDP-22-001245 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK cr CITY YARMOUTH MA DATE 9/2/21 PERMIT# BLDP-22-001245 wn-: I JOBSITE ADDRESS 248 CAMP ST UNIT B2 OWNER'S NAME WIMER WILLIAM E P OWNER ADDRESS 248 CAMP ST UNIT B2 WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO El FIXTURFS • 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 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 1 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 El 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 Andrew Mikita LICENSE 10843 SIGNATURE MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# 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 ❑ El rwrimarr FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTSUNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 2 Crr rowN y/Y R o art/ •MA DATE 8-30 / PERMIT# JOBSITE ADDRESS a y' tR r>n1J s AI 13-oZ OWNER'S NAME a ll U 1431*Pi F POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE • COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL L( PRINT CLEARLY NEW:❑ RENOVATION:❑ .REPLACEMENT:[ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7. FLOOR-4 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/0IUSAND 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 WATER HEATER ALL TYPES WATER PIPING f OTHER - 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 POUCY OTHER TYPE OF INDEMNITY 0 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 I hereby certify that all of the deWls 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 with all P •nent of the Massachusetts State Pkumbing(Code and Chapter 142 of the General Laws. Q�/ !3 PLUMBER'S NAME /jNAY .% /?)(Kt%f LICENSE#//O GNATLIRE MP 0 JP( ' CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME / if iT�N Plc ADDRESS / • '3"Y 6•46 ' Cn J • / /%204 G STAT61l!Y ZIP 0,7ZG/ TEL . d5 'c237-Ya r? FAX CELL EMAIL • The Commonwealth of Massachusetts *_, —v �_!!, Department of IndustrialAccidents ; 1 Congress Street,Sw'iIP 100 Boston,MA 02114-2017 • wwwmass.gov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED'ATM THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name{Businesslorgaaization,'Individual): Address: City/State/Zip: Phone#: Are you an employer?Cheek the appropriate how Type of project(required): LEI I ama employer with employees(full and/or part-time).* 7. ❑New construction. 2.0 I am a sole proprietor orpartnersbip and have no employees working forme in 8. Remodeling . any capacity.[No workers'comp.insurance required.) 3.0I am a homeosvnerdoing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a hormeawner and will be hiring contractors to conduct all work on my property. I win 10 Building addition ensure that all contractors either have workers'compensation insurance Or are sole • 11.Q Electrical repairs or additions proprietors"ith no 12.0 Plumbing repairs or additions 5.0I am a general contractor and I have hired the sub-contractors listed on the attached shed. These sub-eont actors have employees and have workers'comp.insurance.: I3.nRoof repairs 6.0 We area corparatiasnand its officers have eznicised their right of exemption per MM.c. 14.QOfiber • 152,§1(4),and we have no employees.[No workers'comp.insmancerequired.J *Any applicanttbat checks box g1 most also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this afidavitindicating they are doing all work and then hire outside contractors must submit a new affidavit iodinating such. *Contractors that check this box most 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 providetheir workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Itelow is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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: Phone#. 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): L Board.of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: