HomeMy WebLinkAboutBLDP-26-320 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
t CITY/TOWN I ( OJ MA DATE ti I Z 3 ( 2(o PERMIT# JP 26 ^ J
JOBSITE ADDRESS 3 6, 11� lA A 6 4,4 Coy t, C t(I‘`‘OWNER'S NAME Ft:. "ka,:L•.
OWNER ADDRESS TEL I I C6 b log I FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL E
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: EY 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 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 t E C E I V E
URINAL 1
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
r
WATER PIPING _ j t � to 2025�
OTHER
[ EUILDI4G DEPARTPAACNT
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES"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 ❑ 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.
PLUMBER'S NAME pawl y0.c(601 So-„1_ LICENSE# 17 `1 Z cam/ SIGNATURE
MP JP❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME 9 c,1. tM-r l wt^S u.-. ` ADDRESS I// C'r vk14 wt C✓G)5 5 i '�►f
CITY S !L (t STATE/1/1„¢ ZIP 0 Z (oZq TEL 5-61 7 Z <�Pir
FAX CELL EMAIL 04.1 U 5 k t yi4On , ( o+^,
C Vl.e c l4 A4 1 aa8' �� _
OMMONWEALTH OF MASy ACHUSE `.,;
DIVISION OF 40 CCUPATIONAL LICENSUF3E
BOARD OF
PLUMBERS AND€A;FITTERS
ISSUES THE FOLLOWING LICENSE
MASTER PLUMBER "` I;
DANIEL E MELANSON
41 TWICKFNHAM XING
W BARNSTABLE,MA 02,368-1153 z
J
12926 eta
05/01/2026 571865
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
The Commonwealth of Massachusetts
x— Department of Industrial Accidents
Office of Investigations
-le_?' Lafayette City Center
_.4)_
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): D 4 41 ti/Ce,,D h _
Address: ( 1 ft.() C/a
City/State/Zip: (,>, G/A Phone#: c t 2 l - /B'P'
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 6. New construction
ptnployees(full and/or part-time).* have hired the sub-contractors
2.Un 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' 9. ❑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.❑Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.0 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.Lie.#: 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 certifyun�drer the pains and penalties of perjury that the information provided abovecorrect
b is true and
Signature: lest"/J z l' tr/ " Date: 4/Zy/7,(
Phone#:
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 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.0Other
Contact Person: Phone#: