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HomeMy WebLinkAboutBLDP&G-23-003869 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1 0,,,1/4�, CITY YARMOUTH MA DATE 1/17/23 PERMIT# BLDP 23 003869 JOBSITE ADDRESS 151 CAPT NOYES RD OWNER'S NAME BROWN ARTHUR W JR P OWNER ADDRESS BROWN NOREEN A 151 CAPT NOYES RD SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURES z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 1_1 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 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 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 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. 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. PLUMBERS NAME Michael Mcbride LICENSE 10681 SIGNATURE MP 0 JP 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME MICHAEL R MCBRIDE ADDRESS 9 Rustic Drive CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbride@gmail.com ..- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK K._rr /A 'T"_e,+ CITY/TOWN 5 q rill d U MA DATE I 71 ( 1/7� �PERMIT#z� ' 3>f('s JOBSITE ADDRESS /51 C4PY Ae11 5 /2J OWNER'S NAME �,/!4i'i-e'j /5rx.-'/j OWNER ADDRESS (/ / TEt 73 9 /lO FAX TYPE OR OCCUPANCY TYPE • COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL(S PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:la ' PLANS SUBMITTED: YES Q NO i FIXTURES 7. FLOOR-+ I3SM 1 2 3 4 5 6. 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _ . DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM . DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN R E C E I V E D V FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) JO 13 2023 KITCHEN SINK LAVATORY BUILDING DtiHRTII ENT . ROOF DRAIN I By. — , - SHOWER STALL SERVICE!MOP SINK TOILET . URINAL WASHING MACHINE CONNECTION WATERHEATER ALL TYPES 1 WATER PIPING OTHER L L 1L) Gi 3 r -n:7- ESTIMATED VALUE OF WORK: I t It III I. I I III II INSURANCE COVERAGE I have,a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 14 NO [I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ OTHER TYPE OFF INDEMNITY ❑ BOND 0 - OWNER'S INSURANCEWANER: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 0 SIGNATURE OF OWNER OR AGENT i hereby certify that at 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 Piumbin Code and Chapter 142 of the General Laws. (�/ n n' I 61. l -SIGNATUREE V` PLUMBER'S NAME (c r PC 1 (13 l r ye LICENSE# C / MP 0 JP[ CORPORATION❑# PARTNERSHIP 0 it LLC❑# COMPANY NAME I v 11CJc) (1 Jf p i_ if ADDRESS 3 7 r/ /iL/., 4, Atha. - CITY I GI /1 /`i STATE Al— ZIP 0 7.6 Q / TEL 77 Y g/d 9/7Z FAX CELL EMAIL j-tnl-0/`•AtC [6 f a 600•AL+IL. (o.,. cICt - • The Commonwealth of Massachusetts 1' --s1. p ` Department of Industrial Accidents '_ �' 1 Congress Street,Suite 100 `:=1 i=� Boston,MA 02114-2017 �� ,�, •wwwtmass.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: • City/State/Zip: Phone#: Are you an employer?Check the appropriate box Type of project(required): 1.Q I am a employer with employees(full and/or pa:t-time)* 7. ❑New constrnction 201 am a soleproprietor or partnership and have no employees working for me in 8. Remodeling . any capacity.[No workers'core.insurance required.] • 3.0I am a homeowner doing all worlcmyself.[No workers'comp.iaa*.anre•requusd.3 t 9. ID Demolition 4.❑I am a homeowner andwtll be hiring contractors to all work on ray property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or am sole 11.0 Electrical repairs or additions pruprietetts with no employees. 12.0 Plumbing repairs or additions • 50I am a general contractor and I have hired the sob-contractors listed on the attached sheet These subcontractors have employees and have workers'comp.insurancet 13 Roof rejpaiYs 6.0 We area 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.] *Arty applicant that checks box#1 must also fill out the sectiionbelow showing their workers'conpeasatiou policy information. t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box mast attached an additional sheet showing the name of the sub-contractors and state whether those entities have employees. If the sob-contactors have employees,they must ptovidetheir worlcets'comp.policy member. 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_Lic.#: 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#: - e 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `''�" cri CITY YARMOUTH MA DATE January 17,2023 PERMIT# BLDP-23-003869 JOBSITE ADDRESS 151 CAPT NOYES RD OWNERS NAME BROWN ARTHUR W JR G OWNER ADDRESS BROWN NOREEN A 151 CAPT NOYES RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER • CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST • UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 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 ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER 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-GASFITTER NAME Michael Mcbride LICENSE# 19681 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑it COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinaer.mcbride anpmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION;FOR A ERMIT TO PERFORM GAS FITTING WORK .- Tt_Ce ��� Rj_l_r_zji_aii__ y1/_ GTY /1 MA DATE Z0 Z PERMIT# Z3` If('5 G! JOBSITE ADDRESS /3 / (/ T l4VM/�s omen S AIAME,04�?.k^ �'D"'�y'I 11 OWNER ADDRESS /f TEL' FAX FAX t TYP p R OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIALgI CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:Ft PLANS SUBMITTED: YES❑ NO[d APPLIANCES T FLOORS-' BSM 1 2 3 4 ` 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER • DRYER • FIREPLACE FRYOLATOR FURNACE GENERATOR - GRILLE INFRARED HEATER 1 R LABORATORY COCKS I V E D MAKEUP AIR UNIT _ -OVEN BAN 13 2023 -POOL HEATER • ROOM 1 SPACE HEATER l3UILD:N(3 utT Ak I ME VT ROOF TOP UNrr 3Y TEST — .--_ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER / i OTHER ESTIMATED VALUE OF WORK: - • T I I I l I I I I I I t t 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)* N I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not halm 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 au 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 Ater 142 of the General Laws. I Ci / <D-. / PLUMBER-GASFITTER NAME N, 1 CMC A L ( f I LICEEN12SE# SIGNATURE�",L___. MP❑ MGF❑ JP[ JGF❑ LPG! CORPORATION❑# I v ra P PARTNERSHIP❑# LLC❑# COMPANY ME ( 1 1 "` � h y--ii ADDRESS a 7 ri-G/1Lz, t/1 /—v-e4 lJC I CITY % lI 71 f S STATE_ LO ZIP Z Ira_ 7 ?*//C FAX CELL EMAIL -'1 M + CLt r�Lir�2 l L' c aF • • The Commonwealth of Massachusetts pepartment of Industrial Accidents .wr1 Congress Street,Suite 100 • Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE TILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Legibly Name(Bnsiness/Organizatiion/Individual): Address: City/State/Zip: Phone#: • Are you an employer?Check the appropriate tar. Type of project(required): 1.Q I am a employer with employees(furl and/orpart time).* 7. ❑New construction 20I am a Bole proprietor orpartnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.12I am a homeowner doing all work myself.[No workers'comp.insurance required]t 9. El Demolition 10 Building addition 4.0I ama homeowner and will be hiring contractors to conduct aft wodconmy property. 1 will ensurethat all contractors either have workers'compensation insmauce or are sole 11.0 Electrical repairs or additions proprietors with no employees. • 5 Q I am a general contractor and I have hired the sub-contractors listed on tine attached sheet 12. Plumbing repairs or additions These employeessub-contractors have and have wworkers'eecomp.mnidnra= 13.0Roof repairs • 6.0 We area corporation and its officers have exercised their right of exemption per MO.c. 14•['Other • 152,§1(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that chexla 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. tam/rectors 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 ntmtber. 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.Lic.#: 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: