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Home My WebLink AboutBLDP-23-005077 • F MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK A4 I CITY YARMOUTH MA DATE 3/15/23 PERMIT# BLDP-23-005077 r JOBSITE ADDRESS 60 BROADWAY UNIT 15 OWNERS NAME KENNETH CATALDO P OWNER ADDRESS 25 OLYMPIA AVE WOBURN 01801-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0 FIXTURES 1 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 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION 1 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 0 OTHER TYPE OF INDEMNITY❑ BOND 0 OWNERS 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 ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# 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 0 ❑ FEES$ PERMIT# PLAN REVIEW NOTES T 7.1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ` ., /1/1416e..) MA DATE /D/ ,SAPP-Z3- SG 77 CITY/TOWN wes)" z PER Iva 6D 614 1.41277D '7;a: /S OWNERS NPJ E[4Qfl4/ (q71 t/d 'p OWNER ADDR 2A-11 yor,/ AW'c ,�I7 TEL f 27- 3—5 FAX TYPE,OR OCCUPANCY TYPE • COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL( - PRINT CLEARLY NEW:dB RENOVATION:0 -REPLACEMENT::0 PLANS SUBMITTED: YES❑ NO Oid FIXTURES 1 FLOOR-* RIM 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 I AREA DRAIN • INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY / . _ROOF DRAIN SHOWER STALL SERVICE/MOP SINK _ R E C F V E D TOILET ./ URINAL WASHING MACHINE CONNECTION MAR 13 ZUZ? WATER IEATER ALL TYPES WATER PIPING BU LDIN►i ui=NARTMENT OTHER By - _ESTIMATED VALUE OF WORK: ► i I I I i i' { I I I i I 1 I __ INSURANCE COVERAGE:- - I have,a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES A NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Et OTHER-TYPE OF INDEMNITY ❑ 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 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 Pa Massachusetts State bang Code aridn Chapter 142 of the General Laws. A_ PLUMBER. NAME C 114 0 V v l((Lf Q e L- LICENSE# / / / SIGNA1IIRE - MP 0 JP CORPORATION 0# PARTNERSHIP 0# / / LLC 0# COMPANY NAME IR(J3 r i (X� p-/-0_ ADDRESS 3 7 fsl 1 v-'(//6 4- /2 L/ t CIlY V— .4 G(VA,0 0 J STATE ZIP z,62, / TEL 77/ WM ?J 2Z FAX CELL EMAIL 5/1 n c., PJ . MC.)3('/A9dp,(icv¢I C'WAN �&as 1(50 ' • • The Commonwealth of Massacluisetts Department of Industrial Accidents ='=1Farii= 1 Congress Street,Suite 100 Boston,MA 02114-2017 • • .www.massgov/dia . Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plnmbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employee?Check the appropriate box Type of project(required): 1.Q I am a employer with employees(fun and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor orparmership and have no employees working for me in 8. []modeling . any rapacity.[No worker'comp.in:armee required.] • LJ 3.01 am a homeowner doing an work myself.[No worlaas'camp.insurance regaazd.1 t 9 Demolition 14[J Building addition 4_0I am a homeowner andwiill be hiring contractorsto conduct all work on my property. I will ensure that all Contndoa either have workers*compensation insurance or are sole 11.D Electrical repairs or additions propntdors with no employees. 12.El Plumbing repairs or additions 50 I ama general raotxa'truand I have hired the sub-contractors listed on the attached sheet. These have employees and have wadmrs'comp.*s t 13.DRoof repairs ' 6.0 We area corporation and its others have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Ate applhcantthat checks her#1 must also fill out the section below showing their workers'cotton policy informaaion. t Homemynas who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit in g such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-conhactots 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: 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 furweeded 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 of cial f 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#: