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Home My WebLink AboutBLDP-26-347 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1,,1"'—_`"114 CITY/TOWN TQf1140K141 MA DATE Apraaq Ras PERMIT# 19-26-347 JOBSITEADDRESS 31 VIIM0C2 OWNER'S NAME NldPy Nah-riSsit POWNER ADDRESS 4, TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Nd PRINT CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑ FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK URINALTOILET ✓ RECEI _ ED WASHING MACHINE CONNECTION WATER HEATER ALL TYPES APR 2 9 026 WATER PIPING OTHER Du OINe DE •rCTnntN By INSURANCE COVERAGE: 1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES p[I NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY® OTHER TYPE OF INDEMNITY 0 BOND E 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 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. . . ) _L 1 PLUMBER'S NAME [re✓l+ B(IS5e l( LICENSE# 3041 V IGNAT_U(RE p[J MP 0 JP 0 CORPORATION❑# PARTNERSHIP 0# LLC # COMPANY NAME ECB Property Mat/t'-'eloflu ADDRESS for Delerceof Cr CITY Mushpee STATE MA ZIP 6a6gq TEL r'/ Sa1 �o►'� FAX CELL EMAIL OaPropediMaIA+enarlct 60%0I,cam qo Ci4s� • Commonwealth of Ma . =....0 etts Division of Registrati.4 Board of Plumbi.• ruerruar. = s • Brent Cr. - ==- » "=AIP 7= r 108 Dee . . a Mashpee, •,v -_ y Joumeyma . N.:am e`� PL36747-J 05/01/2026 o�M S�� 0011233 License No. Expiration Date. Serial No. • • • • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1�1= Lafayette City Center =1 _ 2 Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information i�.pp t� Please Print Legibly &Name(Business/Organization/Individual): t'('01�([M HaIA'&2nae i _ Address: !Of ('e((so4- Cr I 1 City/State/Zip: Phone 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. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in anycapacity. employees and have workers' P tY 9. ❑Building addition [No workers'comp.insurance comp.insurance.1 required.] 5.❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑I am a homeowner doing all work officers have exercised their 11.[['Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c.152,§I(4),and we have no employees.[No workers' 13.0 Other 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 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. �y Insurance Company Name: RogrPSsiUp Policy#or Self-ins.Lic.#: KR 473433433 Expiration Date: Y /S 2621. Job Site Address: 31 c7It'eOI Rd City/State/Zip: K1(mottk 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$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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: ��r 1 ',�- (i Date: ' /�q -a( Phone#: 7 ( 52I Nl't Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5 Plumbing Inspector 6.0Other Contact Person: Phone#: