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HomeMy WebLinkAboutBLDP-21-007319 . ;,• .. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK c/ CITY YARMOUTH MA DATE 6/16/21 PERMIT# BLDP-21-007319 '- JOBSITE ADDRESS 27 BLUEBERRY PATH VILLAGE OWNER'S NAME donna potter P OWNER ADDRESS 27 BLUEBERRY PATH VILLAGE YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO 0 FIXTURES 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/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 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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 Ryan White LICENSE 16068 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME RYAN L WHITE ADDRESS 19 SKIPPERS DR CITY Harwich STATE MA ZIP 026453122 TEL FAX CELL EMAIL rwhite1011@gmail.com 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 "`— CITY/TOWN V4r•Ntdoj�l/� .MA DATE - - ZLDP ( PERMIT#Q -`Z(-o0"1T1� "Dor------=:-7 1/4j.,.., `fi-=-�,� JOBSlTE ADDRESS a —T Q 1 veb c r-� al OWNER'S NAME w on q tier- PJ) OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE • COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL E PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:V PLANS SUBMITTED: YES 0 NO 0 FIXTURES 7. FLOOR-, BSM 1 2 3 I 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 SYSTEM _ DISHWASHER - _ DRINKING FOUNTAIN FOOD DISPOSER FLOOR!AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN _ _ SHOWER STALL SERVICE I MOP SINK TOILET URINAL , WASHING MACHINE CONNECTION WATER HEATER ALL TYPES i _ . WATER PIPING OTHER _ . INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES g/NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY 'd` OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAVER: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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT i hereby certify that al of the details and tion I have submitted or entered regarding this.appftcation are true and accurate to the best of my knowledge that all plumbing work and installations*formed under the permit issued for this application will be in • with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ l •\ LICENSE# [& C' V / SIGNATURE MP Oa/ JP❑ CORPORATION❑# PARTNERSHIP 0# LLC❑# y COMPANY NAME lrL (� r H-- ADDRESS PO 60 r< Y Z CITY is)a<w STATE ZIP C/Z_CO Y c TEL Sties 2-`1J6 7 S 7 F FAX CELL EMAIL FIG-6:14 /a It 6 4 l• C*-'""- The Commonwealth of Massachusetts —ft Department of Industrial Accidents tik :11tl= 4 I Congress Street,Suite 100 :=„; Boston,MA 02114-2017 ,;�, www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leuibly Name(Business!Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0I am a employer with employees(full and/or part time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working forme in 8. Remodeling any capacity.[No waiters'comp.insurance reguire:Li 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required]t 9. Demolition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insuranc•t 13.0 Roof repairs 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'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. tContractors 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 subcontractors 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.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#: