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Home My WebLink AboutBLDP-26-311 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY S yam r`c4-1-, MA DATE Li 4 a b PERMIT# S-0 P-24- JOBSITE ADDRESS I") rife t z y I)c"'I. OWNER'S NAME POWNER ADDRESS 7 r ShJt or 41,4 �'y �J TEL 4') 144 Io 71f FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL S— PRINT CLEARLY NEW:❑ RENOVATION:El-- REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO El— FIXTURES 7 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 SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL A. _ SERVICE/MOP SINK R { ,a TOILET URINAL WASHING MACHINE CONNECTION ' WATER HEATER ALL TYPES WATER tir+ ._ OTHER PIPING u c Cbtfel,##� 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 POUCY❑ OTHER TYPE OF INDEMNITY 0 BOND❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Ma sac setts General laws,aand that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER❑ AGENT❑ SIGNATURE 0 J R 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 etts State plumbing work and installations performedunder the eneral issued for this application will in ace vyfth all Perh revision of the Massachusetts Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME /Vpc1' Li,0104411✓1en LICENSE# 35 I2y SIG RE MP❑ JP® CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME ADDRESS 114 •L U/'}lS Ai �N CITY r II 1 C&1 Sbaj STATE/VI ZJP a I""/�(9 NGj TEL N/3-3 20-,�,7 32 FAX CELL EMAIL rvOAL/I101 52,&jinail.Cool i3,o (kit CIS ��w ...."\\ The Commonwealth of Massachusetts 4 4s,lio -,.. Department of Industrial Accidents ilk Office of Investigations Lafyette Citya Center 2 .,4venue de Lafayette, Roston, MA 02111-1750 .,.... . www.mass.goviidia Workers' Compensation Insurance Affidavit: fluilders/ContractorsiEfectriciansillumbers Applicant Information Please Print LegibtY _.. . Name musinesworgartizationandividuao: 4/0041 le, ; i' 014.-t "(pi' ic: 11. ,, ,,, ______ _. Address: '., 'I_ 1 . ,/ : 3, i' 4-c.: ._;!kl' lici _ ._ _ , . . CityState/Zip: \A/ il I CIO\6 b1/4iiti 4:1, A (;) . ' ) j ' Phone #: 11 — 3 2t7 - ,57 3 Are you an employer? Check the appropriate box: Type of project (required): 1 . ...] 1 am a employer with 4. Ej I am a general contractor and I 6. 0 New construction employees (full and or part-time).* have hired the sub-contractors 2. LA.i.7 I am a sole proprietor or partner- listed on the attached sheet. 7. 21 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity, employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3 11 1 am a homeowner doing all work officers have exercised their I 1 .0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL I 2.0 Roof repairs L___::_insurance required.] t C. 152, §1(4), and we have no I 3.F1 employees. [No workers' Other — comp. insurance required.] Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 7. 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 cheek this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have emploees. if the sub-contractors have employees, they must pros ide their workers' comp. policy number. _---.------,------ I am an employer that is providing swrAers' compensation insurance for my employees. Below is the policy and job site information, Insurance Company Name:_ Policy # or Self-ins. Lie. #: Expiration Date: e . Job Site Address. / -7 1.?:-.ce z 1 . i'' . - /- 04 City/State/Zip: ,\ y4t.?IN:, v 14\ 414 0 j (.,,i6. 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 S1 ,500.00 and/or one-year imprisonment. as well as civil penalties in the form of a STOP WORK ORDER and a time of up to S250.00 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 certilv under the pains an penalties qfperjury that the information provided above is true and correct .,- - ,.., Si Dei gnature: //,-,z," 7 /2C) at : Y/ ,. ,,?-,t.," - i j‘ i • "2 -1, ,,4'` — *-7 1 1 . Phone #: il ...) .4-4- ,, 5..Z...77,, ....___ __________ Official use only. Do not write in this area, to he completed by city or town official. ---1 , .,, City or Town: _ Permit/License # - - Issuing Authority (check one): '# ,.. I OBoard of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5Filumbio11 ,. inspector 6.00ther Contact Person: Phone #: - -- _ _