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HomeMy WebLinkAboutBLDP-21-000743 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w • CITY YARMOUTH MA DATE 8/16/20 PERMIT# BLDP-21-000743 „k JOBSITE ADDRESS 5 BOXWOOD CIR VILLAGE OWNERS NAME MARIE DESMOND P OWNER ADDRESS 5 BOXWOOD CIR YARMOUTH PORT 02675-1478 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL m PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:© PLANS SUBMITTED: YES❑ NO 111 FIXTURES i 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 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El 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 LEVESQUE LICENSE 1)5162 SIGNATURE MP © JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME HARWICHPORT HEATING AND ADDRESS 461 LOWER COUNTY ROAD C001 ING CITY HARWICHPORT STATE MA ZIP 02646 TEL FAX CELL EMAIL andy@hphcllc.com ARM., S 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 1 i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY/TOWN YARMOUTH MA DATE 8/4/2020 PERMIT# /-'Dow JOBSITE ADDRESS 5 BOXWOOD CIRCLE OWNERS NAME DESMOND p OWNER ADDRESS 5 BOXWOOD CIRCLE TEL 617-968-9895 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES 0 NO FIXTURES 1 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/OIL/SAND SYSTEM ' DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 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 ALL TYPES 1 WATER PIPING - OTHER INSURANCE COVERAGE I have a current liability insurance policy or Its substantial equivalentwhich meets the requirements of MGL.Ch.142 YES [YNO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE 130X BELOW LIABILITY INSURANCE POLICY V' OTHER TYPE INDEMNITY ❑ BOND ID 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 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 Andrew Levesque LICENSE# PL1 5162 GNAT.0 MP MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC szf# 3944 COMPANY NAME Harwich Port Heating&Cooling LLC ADDRESS 461 Lower County Rd CITY Harwich.Port STATE MA ZIP 02646 TEL 508-432-3959 FAX 508-432-6075 CELL 508-958-4874 EMAIL andyAhphcilc.com kecia@hphcllc.com RECEIVED j AUG 112020 BUILDING DEPARTMENT By li • The Commonwealth of Massachusetts Department of Industrial Accidents r vs.--: Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Harwich Port Heating&Cooling LLC Address: 461 Lower County Road M City/State/Zip: Harwich Port MA 02646 Phone#: 508-432-3959 w Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with 75 4. [] I am a general contractor and I employees(full and/or part-time). have hired the sub contractors 6. M New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. M Remodeling ship and have no employees These sub-contractors have g. 0 Demolition 1 workingfor me in anycapacity. employees and have workers' f P tY 9. GM Building addition [No workers'comp.insurance comp.insurance.t required.] • 5. ❑ We are a corporation and its I0.M Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.M Plumbing repairs or additions k myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs N insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.M Other HVAC comp.insurance required.] 1 '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: Selective Insurance Company of South Carolina I Policy#or Self ins.Lie.#: WC9059813 Expiration Date: 10/26/2020 Job Site Address: 5 BOXWOOD CIRCLE City/State/Zip: YARMOUTH Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ! E 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 violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cere nd a0d penalties of perjury that the information provided above is trite and correct. • Signature: Date: 8/3/2020 , ?bone#• 508-432-3959 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License ll issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector i 6.Other Contact Person: Phone It: I ;l 1