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Home My WebLink AboutBLDP&G-26-506 —� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r-""__- CITY/TOWN <55,yq rfvl n /t� MA DATE_. /ir:Z.44 1 ' PERMIT# ku>P 26 JOBSITE ADDRESS 3 y- ` 4 / !✓ 9/�� OWNER'S NAME I c n1�-e/ P OWNER ADDRESS / (77Y/I EL F7O—Z(o6/ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[a PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES❑ NO ga 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 GAS/OIUSAND 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 I MOP SINK R E C E I V E fl TOILET UL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES / WATER PIPING 3UILD NG DEPARTMENT OTHER —____-_-____-- INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES a 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❑ 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❑ 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 Plumbin Code and Chapter 142 of the General Laws. q 2 PLUMBER'S NAMEVIA lc Aj 1' NI,� rt (Q„pnn LICENSE# `�I SIGNATURE MP 0 JP t CORPORATION 0# p f'Q P, PARTNERSHIP❑# /' LLC 0# COMPANY N E Y 0:3'n r t�ly t'�L� /ADDRESS 3 7 "�-//l l/ Liele 4e7 CITY v 4 n'l t S STATE I4it ZIP (� Z CO Q/ TEL 7)V Y// 9v Z Z..,FAX 6666 CELL EMAIL 5,Y,1 C/''/17Ge r7do®.. ik4 i1. (041 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Ct — n je€'- —t CITY SCJ �''M C� MA DATE 4 PERMIT# ''`Z(r-.S-06 ' v JOBSITE ADDRESS 3 g//cr. j '`-'j OWNER'S NAME/bell —77 C OWNER ADDRESS 77Y TEL i�ld- Z647 FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL a PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: 51 PLANS SUBMITTED: YES❑ NO APPLIANCES Z FLOORS BSM 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 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVE POOL HEATER 1 R E C ROOM/SPACE HEATER j ROOF TOP UNIT TEST JUN 11. 2 2926 i UNIT HEATER UNVENTED ROOM HEATER BUtLUirjc .LIAR(MINT Ry WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES t4 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a OTHER TYPE 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. 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. / 7 O _D �] PLUMBER-GASFITTER NAME 1114.A19P"tL� r t Off' LICENSE# ! l SIGNATURE MP❑ MGF❑ JP [0 JGF❑ LPGI ❑n CORPORATION ❑# PARTNERSHIP ❑/# LLC❑# COMPANY AME jU`(J� r I ti' �� ADDRESS 3 7 /C l�1,'�C!/�/ 6� CITY I Gi/1✓\/ I 5 STATE// 4 ZIP C.tDO / TEL 7 7r Y7 7/e- FAX CELL 7 Y�lL� E/Z Z EMAIL )JJt(1)LL/s f1 rJ /t< 430. #144/ L (Q"-, ( 27(c7 The Commonwealth of Massachusetts a�= Department of Industrial Accidents _w10 ' Office of Investigations —_ } — ' Lafayette City Center em. , 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):• 1 / c�a Address: _.) U )LP City/State/Zip: ( 5 f otil ortiq Phone #: 77 11 7/6 2/ 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.al am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p �' $ 9. El Building addition [No workers' comp. insurance comp. insurance. 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(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. 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: 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 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: f Date: 6 4.//z_ ... Phone#: J )6( TO ehZZ 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): 11=1Board of Health 21:Building Department 31:City/Town Clerk 4.1:Electrical Inspector 51:Plumbing Inspector 6.❑Other Contact Person: Phone#: The Commonwealth of Massachusetts Department of Industrial Accidents L — 3' Office of Investigations - Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 .:tom' ww>".mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information t� Please Print Le'ibly Name (Business/Organization/Individual): A ! G�ct 'i ill ci3 r )c�A — Address: 7 F7 ,1,6,-(//i Amy* City/State/Zip: 1 14- Phone #: ?2 T/ ' j/Z z Are you an employer? heck the appropriate box: Type of project (required): 1.D 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. El New construction 2.2-4--am 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' insurance.t 9. ❑ Building addition comp.[No workers' comp. insurance 10.0 Electrical repairs or additions required.] 5. El We are a corporation and its 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(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. I.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. 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 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: ��_/e i\-- — K----•• Date: Phone#: .77c71`16 if 2 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): 1❑Board of Health 20 Building Department 3EICity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: COMMONWEALTH OF MASSACHUSETTS Division of Occupational Licensure Board of State Examiners of Plumbers and Gas Fitters Plumbing Journeyman 4446/ Michael McBride 37 FRANKLIN AVENUE. HYANNIS, Massachusetts.02601 EXPIRATION LICENSE NUMBER 5/112028 19681-PL-J MASS.GOV/DPL