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Home My WebLink AboutBLDP&G-26-338 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT PERFORM PLUMBING WORK T. @ CITY Vil J G /M a_V MA DATE Zts PERMIT# p26 338 JOBSITE ADDRESS//E 1SUCIL..i.-04.- (I) G2 OWNER'S NAME LeL/i"4' 0 � IL, P OWNER ADDRESS 6 UCk.�5ULJ( [y/71 L F 7-7 s-riFAx TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL 17 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[iif PLANS SUBMITTED:YES❑ NO(k FIXTURES 7 FLOOR—, 8SM 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 SYSTEM DISHWASHER ' DRINKING FOUNTAIN FOOD DISPOSER _ — FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL C ' _E-17_ WASHING MACHINE CONNECTION ) WATER HEATER ALL TYPES / WATER PIPING _ _ t OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES t NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ria OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. T CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 1 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 M\G PL ,v`L C.-t LICENSE# 1 9��/ SIGNATURE MP 0 JP u_ CORPORATION #PCO� PARTNERSHIP❑# LLC 0# COMPANY c E M 33 rV j Q P T '? r� "�T ADDRESS', el 1-- thre--.1 1/14'Y CITY l- 1 /\ k. 5 STATE /VAr ZIP 17(y.0 I TEL 77 `/ T/O //Z FAX CELL EMAIL n c 'L ' (O ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT # PLAN REVIEW NOTES &Z., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT T E ORM GAS FITTING WORK r CITY:i 1L/V/ �Al o�' MA. DATE:. `? c/7yZ�I/ PERMIT#-24-338" JOBSITEADDRESS716UUC. C V/L4A4EOWNER'SNAME: s LW'4 OQ LL G OWNER ADDRESS'UNJr// --- ('17 TEL:)77-2i FAX: TPTA OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL ' CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO I}a APPLIANCES? FLOOR-. Burnt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ . GENERATOR _ GRILLE l INFRARED HEATER W LABORATORY COCK MAKEUP AIR UNIT POOL HEATER it ..,..-"tt .n<t69t R9 ROOM/SPACE HEATER i J ROOF TOP UNIT fi TEST �Z u 7WV Z UNIT HEATER ryj UNVENTED ROOM HEATER a i 2 N WATER HEATER / ili INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES il NO❑ If you have checked la please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY g_ OTHER TYPE INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:1 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 hereby certify that all of the details and informationI have submitted(or entered)regarding this epptcation are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit Issued for this appllcaton wlb be In compliance with all Pertinent provision of the Massachusetts State Rooting Code nand Chapterpt 142 of the General Laws. / _ 2 PLUMBER/GASFITTERNAME:1-`(Jcl _ V I 1�. LICENSE: AI/' ISGNAT E 'La 1 9 1 v COMPANY E:1M� r I� '� "'f-��/ADDRESS: .�G/��l/✓J `P�n/JF CITY: /. /l1 /"-A L 5 STATE:i�/4 21P: 6 Z.Ln() / FAX A TEL: ?/I1 l ii 7(I'2� CELL: EMAIL ��J1 �_C�Q r�Lv®^ylcall r 1Q rin MASTER 0 JOURNEYMAN g LP INSTALLER❑ CORPORATION 0#42 `TNERSHIP❑# oP LLC❑# EMIiiL ADDZesS: , ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes Na THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i /sc V ivls►r v..is sI• vJ . v rLD N VIA If.V Vi.'ai 4"1 Department of Industrial Accidents rg =" ` Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass. ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ness/Or antion/Individual : 1 ('C g Address: . City/State/Zip: Phone #: J/ V ( d 7 / Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2. Erlarn 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' g ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officershave exercisedtheir 11 .0re 3. El I am a homeowner doing all work Plumbing or additions P myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.0 Other 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. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'ontractors that check this box :must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have eployees. If the sub-contractors have employees, they must provide their workers' comp.policy number. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site formation. surance Company Name:. )licy # or Self-ins. Lic. #: Expiration Date: b Site Address: City/State/Zip: tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a e 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of lestigations of the DIA for insurance coverage verification. o hereby certify under the pains and penalties of perjury that the information provided ab e is tru and correct. nature: �-- •_ Date: `� Z S Z )ne #: 9fficial use only. Do not write in this area, to be completed by city or town official -2ity or Town: Permit/License # ssuing Authority (check one): ®Board of Healt h 20 Building Department 31:CityITown Clerk 4.❑Electrical Inspector 5�lumbing P nspector 6.0Other COM •N ALTH • m.a "A HUS TT DIVISION 'F OCCUPATIONAL LICENSURE BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE 'S JOURNEYMAN PLUMBER la MICHAEL R MCBRIDE 37 FRANKLIN AVE .,„, HYANNIS,'INA 02601-2603 I2 !. 19681 6510i12026 622478 I' is LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER