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Home My WebLink AboutBLDP-26-267 MA?SACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 7r P i n rC(t'f film ovA-1.. MA DATE LA 1.1 1 }to PERMIT# L j�p Zj0'7"7 to AOBRr �SS CaP}a Svna�� 1L OWNER'S NAME ikrkCt.n. —�OWNER ADDRESS TEL 5OQ')B0-- 308 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:tia REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO❑ FIXTURES I FLOOR-. UM 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 3 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET -3 URINAL WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES WATER PIPING I OTHER o Dote- c er / 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 POUCY ISO 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 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 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 inpliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - A4-4,4-velr PLUMBER'S NAME �e/`^ t- S P r`'S LICENSE# t Sr1 b`j SIGNATURE MP JP❑( CORPORATION❑# PARTNERSHIP❑# LLC 3 S-5 ' COMPANY NAME Jpf P�.tr��r.5 ' U.zckrn I LC ADDRESS 4 1 I-n-A v c1 I Le `l0 CITY (2-0 r��.. !L STATE WI Ps ZIP C)...).11 D TEL 1 B I- rt 3'4--00 311 FAX CELL-1 `- 10, -OtoCT EMAIL Cool. -ecc E Cyr �vmi,r g Cof1 C K# 3b�7 a The Commonwealth of Massachusetts i / Department of Industrial Accidents r1= 1 Congress Street,Suite 100 cy_i�e1= Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Sp((.) I"Li:,n�j n S '3 ��P A}yam` L L-C Address: GO- U.d v S tr'ct\ L )a..t3 '-t) City/State/Zip: Phone#: Are you an employer?Cheek the appropriate box: Type of project(required): 1.0 am a employer with S employees(full and/or pert-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.) 3. I am a homeowner doingall work myself. t 9. ❑Demolition ❑ Ys (No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiving contractors to conduct all work on my PPeriY•ro t will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole L 1.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hued the sub-contractors listed on the attached sheet 13.❑Roof repairs These subcontractors have employees and have workers'comp.insurance.* 6.0 We are a corporation and its officers have exercised their right of exemption per MGl.a 14.❑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 *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: A i N J}nt a1 C ow.pa r Policy#or Self-ins.Lic.#: 1,J CC SO O CO I 1 1 $ Expiration Date: S"-)`t a b Job Site Address: 3 'Cct a<„ S City/State/Zip: H Y3 Oru 1.le 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[mprisonment,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 cerlhfy under the pains and penalties of perjury that the information provided above is true and correct, Signature: Q.. v. o s,q tn� Date: 4 1 a (. Phone#: `i 8 t- O j - (y[c. 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: