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HomeMy WebLinkAboutBLDP-21-003747 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ki,,,,,, ` CITY YARMOUTH MA DATE 1/6/21 PERMIT# BLDP-21-003747 JOBSITE ADDRESS 8 BRATTLE DR OWNER'S NAME CARNEY JAMES P OWNER ADDRESS 8 BRATTLE DR YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES ..l FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER 1 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❑ 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 David Renzello LICENSE 113886 SIGNATURE MP © JP 0 CORPORATION ❑# PARTNERSHIP ❑# I I LLC ❑# COMPANY NAME (David M Renzello I ADDRESS 146 1/2 BENEFIT ST I CITY IATTLEBORO I STATE IMA I ZIP 1027031822 I TEL I I FAX I I CELL ( I EMAIL I I t ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • a'= ; CITY YARMOUTH PORT I MA DATE 12• -18-20 , PERMIT#iIY 1 /- � JOBSITE ADDRESS 8 Brattle Drive I OWNER'S NAME McNally,Luana 1 POWNER ADDRESS 8 Brattle Drive ! TEL 508)846-4172 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: I J RENOVATION: REPLACEMENT:I ° I PLANS SUBMITTED: YES—1 NO FIXTURES Z FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ; DEDICATED GREASE SYSTEM 1 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 2 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 2 URINAL I WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES WATER PIPING ___ OTHER valve E �!' I l u INSURANCEII policy COVERAGE: q ti ,iA ! r.n7I ; I have a current liability insurance olic or its substantial equivalent which meets the requirements of MG Ch.142. YES I I NO L IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOWy J V, � `�" " 1 LIABILITY IN• ', CE POLI Y OTHER TYPE OF INDEMNITY CI BOND [, OWNER'S INSURA e Al re that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Ge w h m s' ature on this permit application waives this require..-nt. l�• C I NEON Y. 0 ER 1 I AGENT j SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applicatio - - u u to the est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be j• ,•it( c h P ' nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME'David M Renzello Sr 'LICENSE#110886 -1 SIGNATURE MP , JP CORPORATIONI #I PARTNERSHIPLJ#r LLC #~ 1 COMPANY NAME 1HIP Construction LLC 9 ADDRESS[2C Morgan Mill Rd CITY'Johnston (STATE 1 RI I ZIP 102919 I TEL 1401-942-7897 ____ •^, FAX [� -- 1 CELL — EMAIL permits@rebathnewengland.com 1 } The Commonwealth of Massachusetts Department of Industrial Accidents gl) , . 6 si (,., __ / Office of Investigations Lafayette City Center ` s� W 2Avenue de Lafayette, Boston, MA 02111-1750 M e� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): HIP Construction LLC Address:2C Morgan Mill Rd City/State/Zip:Johnston, RI 02919 Phone #:401-942-7897 Are you an employer? Check the appropriate box: Type of project (required): 1.❑■ I am a employer with 30 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.. Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Beacon Mutual Ins Co Policy#or Self-ins. Lic. #:71967 Expiration Date:6/3/2021 Job Site Address: 8 Brattle Drive City/State/Zip:YARMOUTH PORT MA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 vio r. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ins ance coverage verification. I do hereby tify under t pains and penalties of perjury that the information provided above is true and correct. Signatur . Date: \ \ I —L b a., Phone#: 4 -7897 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1DBoard of Health 21:Building Department 30City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Phone#: Contact Person: Client#: 102893 HIPCONST1 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9/16/2020 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:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)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 any rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Tina Jones NAME: Starkweather&Shepley I PHONE 401 435-3600 FAX No): (A/C,No,Ext): PO Box 549 Maw RESS: TJones@starshep.com Providence, RI 02901-0549 401 435-3600 INSURER(S)AFFORDING COVERAGE NAIC x _INSURER A:Employers Mutual Ins 21415 INSURED INSURER B:Beacon Mutual Ins Co 24017 HIP Construction, LLC d/b/a Re-Bath of RI and Southern MA INSURER c 2C Morgan Mill Road INSURER D Johnston,RI 02919-6320 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFF POLICY EXP TYPE OF INSURANCE INSRW VD POLICY NUMBER (MM/DD/YYYIf) (MM/DD/YYYIf) OMITS A X COMMERCIAL GENERAL LIABILITY BINDER5D5367620 09/15/2020 09/15/2021 EACH OCCURRENCE $1,000,000 Ep CLAIMS-MADE ]OCCUR PREMainEaoccurence) $500,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 I POLICY X JECOT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY 5E5367620 09/15/2020 09/15/2021 COMBIaccNEideDnt)SI $1,000,000NGLE LIMIT (Ea ANY AUTO BODILY INJURY(Per person) $ OWNED ONLY AU X SCHEDULED ' BODILY INJURY(Per accident) $ _ AUT X AU HIREDTOS ONLY X AU NONTOS-OWN ONLY $ r A UMBRELLA LIAB OCCUR BINDER5J5367620 09/15/2020 09/15/2021 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$10000 $ B WORKERS COMPENSATION 71967 06/03/2020 06/03/2021 X STATUTE EORH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) **Workers Comp Information** Proprietors/Partners/Executive Officers/Members Excluded: Mark Pietros-EXCLUDED,Parnter Sean Senno-EXCLUDED,Partner CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HIP Construction,LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 15B Morgan Mill Rd ACCORDANCE WITH THE POLICY PROVISIONS. Johnston,RI 02919 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD MYA #S1590531/M1589358 ........... 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NoISIAla 3b111SN3011 1VNOISS3A01:Id dO :•:.: •••• , liA . ' 0:::::i.i,-4}L‘. . • ::..:.•., •• ::: ••• . 'NO VII ..• ..:'\''''.."''. V II .., il . H -- ., ,,„‘• . ., ••• . . . . .,. .. '. ..•-. . : , .. • :.. . • . . ; •:• m • •••- • .•-.•• ,ol:.:11 ...... • . •:•:•:- ....... .:•:::::::.• ........ ,.... ..... ... ....,....,.. . s 3 ... .... ,.... ..._. .._•". ••..". • ••••••• •• .••• ........_.. im .•..:.. 4,-....,\,........... .. ___.„... Please visit our web site at http://www.mass.gov/dpl/boards/PL DAVID M RENZELLO SR HIP CONSTRUCTION,LLC 2c MORGAN MILL RD (PL) JOHNSTON, RI 02919-6321 PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED PLUMBING CORP DAVID M RENZELLO SR HIP CONSTRUCTION,LLC 2C MORGAN MILL RD JOHNSTON, RI 02919 4393 05/01/2022 983222