The URL can be used to link to this page

Home My WebLink AboutBLDP-24-41 f 191). FWg ea.( : 1 ifo ,6- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK :CM . -:•-i•-'V•• CITY M of MA •DATE l I rt4 7..DZ`il PERMIT# 73 2Y" 4,51- V/ JOBSRE ADDRESS 13-1(0 gC1D 1, STP-EET I4'I OWNER'S NAME M A VT-- S- L-L-C. ' P .OWNER ADDRESS (� I TEL FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Q --- . PRINT CLEARLY NEW:[RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD FIXTURES 1 FLOOR-' RN 1 © 3 4 5 6 7 8 Q 10 11 12 13 14 BATHTUB M<——MI M 5.101111,I I MR ME s I INN CROSS CONNECTION DEVICE MIK1•MIK MI ililli Will iiiiiiii NIB JIM iiiiiiii iiiiiii am imor ins m. DEDICATED SPECIAL WASTE SYSTEM J'_Iiiilli Nisi M—,—ME I J MIS'MINN ME N DEDICATED GAS/OILJSAND SYSTEM Mil'MIMI',JIM 11111111,.1111 NWall IIIIIff MINI 1111111111iiii.;ion',1• p E' DEDICATED GREASE SYSTEM M IIMMI MINI MK N aim Mill_alln 11111111 M"ME_'NM NM DEDICATED GRAY WATER SYSTEM —,MINI MIIIII MB M MIN.M ME OM MIL M 1•_ — DEDICATED WATER RECYCLE SYSTEM N———Hillo Mr—,—NM 1,M mu um pm a DISHWASHER • I to Imp Mot N Mr mil OM M M RIM MI 1•min a DRINKING FOUNTAIN l:_allig ME MI iiiimiiiiillw MEM Mir MEI alli n NMI,MNoir, \, FOOD DISPOSER 11111.:MI MI M;1B MI 111.11111111.PIM Mil illiiiii'miff"nil a ME FLOOR I AREA DRAIN •N'M'MI a Mill 1•Milli JINN M M'M M iiiiiii a- a- 0- Eilis22.11111.111111p1m 1m ill.MIS MINtlIIIM M 1111111_ IIIIIII MIK!MIMI Miff 11111111r1111111. KITCHEN SINK MK':1<a MN PM NM ion mow am am mil am(PIM;lI M MI LAVATORY Ora a Mg P N MIMI IIIIII MIMI MK MIMI MK NMI OM M ROOF DRAIN Man Milli MI NMI INN 11111111.1111 NMI iiiiiiiIMF MEI MR Ma MIN SHOWER STALL ��MOW WAS gilt ills Mi.':l:mu um um__ l um morlirir;Owl SERVICE/MOP SINK —'--nil NMI M,-N--II as,'arm rim'?';'m. TOILET Wit M U—.M M NM MIR MI MI a=.; @ - I71 URINAL 1111111111111.Mr UM No II.1>>>iii11.11 11'N MIMI`:XIII 111111 MI T WASHING MACHINE CONNECTION Mt NMI 11>m Milikarr 11011111..OMB OUR ill Nil,Noir-e lino *Bpi INM111 WATER HEATER ALL TYPES MI=#a;illili Ma Nig,MUM'JIM NMI NNW'111.111111.MB'I OM WATER PIPING 1 � ;� mu Ira TI1 t . '''mold,mania OTHER MIIIIIIIIIIIIIIIIMIIIMIIIIMM!'l>MIMIII `IMMI.N:; 'mu 1u ate`r,mr ERE Mil'g miff 11111.111111111 _IIIIIMMMMINIIIIIIIII Mil MIK NM gm AIM 111111.11111 NMI MIMI MIN IIIIR MIN MIN Ms ail INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES 1�0 ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0T 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 ''and -- : -to the best of my knowledge and that all plumbing work and Installations performed under the permit rued for this application will be in-• .4Alt '-ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • /� - �_ PLUMBER'S NAME D E-'-tAc- Le-c-Lk -- UCENSE#,1-GC' lf, $4 • MP JP a"- CORPORATION❑# - IPARTNERSHIP❑ LLC❑# • COMPANY NAME Deg&4.Co r'c.+' OIN G ADDRESS P. a. 60 /Z Y$ CITY rooJTDPt LE STATE PIA ZIP OtSc(4 y TEL St)8 - Z9 Z. -'7 Z.y • FAX CEi.L 1 EMAIL LECI_Er2-c DEIzE.K.co q AD c.cJr ) Z.V. F an § yS d}� { s ,` . y • • r n ` ` .11.►111111 Miresaaea refire slave wail&aahr .. � t asosionipc I pM4 is1MYtisrmi iatdpsdodpsalm GIs k } ielbm,at*BFtir X 01111ElsmdaSo *44: mans____disdseOfficeat ainwb trim wad awned. _ r I z Zo , y dy� T.m 11b s. ,insommiettelj .:�.; A • 'I.'..'''''..:.:-....'''...'''-r.''....1'1"L.-.:...;-.....''',' n. ri ''''''....'''''''''..„'-'......':'..',.'', s: ''ems :,,'` t h E LICENSEE SIGNATURE 1 LECLERDE01 -- MWOLF ACORCP CERTIFICATE OF LIABILITY INSURANCE DA9i14I20 3rn 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: M the certificate holder is an ADDITIONAL INSURED,the policy(its)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 License 81780862fineCT HUB International New England P"oeE ) rr,Nel.(781 600 Longt02 D14146 ):(781 792-3200 )792-3400 Norwell, INSURERIS)AFFORDING COVERAGE NAIC INSURER A:Arbella Protection Insurance Company 41360 INSURED INSURER B;Hartford Fire Insurance Company 19682 Derek Leclerc DBA Derek Co.Plumbing&Heating INSURER c. PO Box 1248 INSURER D_—_------ Forestdale,MA 02644 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. raR ADo��uBiePOUCY EFF I LTp TYPE OF INSURANCE NNSp�D POLICY NUMBER I rYY1 LIMITS A X COMMERCIAL GENERAL LIA&LRY ! EACH OCCURRENCE S 1,000,000 CLAIMS.MADE X OCCUR X 9520037793 4/9/2023 4/9/2024 DAMAGISES lE TO RENTED,il�c++rrenrni $ 100,000 PT;FME MEDEXPLA!yoneper 1._ S._- 5,000 ,PERSONAL 8 ADV INJURY {i----- 1 r000,000 - GEN'L AGGREGATE LIMIT APPLI S PER: GENERAL AGGREGATE $ 2,000,000 POLICY JE e LOC PRODUCTS COMP/OP AGO $ 2,000,000 OTHER. _ S AUTOOBILE UABRJTY LEOMBI SINGLE LIMIT M ANY AUTO BODILY INJURY per person) $— __—_ OWNED SCHEDULED AUTOSO ONLY _ AUTOSUp BODILY INJURY)Per accdentl S AUTOS ONLY _ AUTOS ONLYY (Per S UMBRELLALW OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS COMPENSATION ISTAUTE L XI�i B EMPLOYERS'LIPLSUYELIASMITr 08WECCU1002 9/3/2023 9/3/2024 500,000 ANY PRO/PMREIEMTBORPARTIOXECUTIVE Y I „E L.EACH ACCIDENT OFFICE In Ni EXCLUDED? N!A �_N. , . . - SOD OOO (W E:L.DISEASE_-EA EMPLOYEE _.._-_ If yes.describe under DESCRIPTION OF OPERATIONS below f E L.DISEASE POLICY LIMIT $ '� DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached I mere specs Is required) CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Proof of coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD