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HomeMy WebLinkAboutBLDP-26-193 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK `�'s_' CITY/TOWN MA DATE PERMIT# =_ 7x'�►—ZG'l93 f ' JOBSITEADDRESS -759 1.14 e Z$ IAI' Y (OWNER'S NAME Sr sw+$Yarn OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0 PRINT • CLEARLY NEW:0 ' RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑ • FIXTURES 1 FLOOR--. 98M 1 2 3 4 5 6 7 8 9 10 -11 12 13 14 BATHTUB — t 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 1 FOOD DISPOSER FLOOR/AREA DRAIN • INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY I7 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET (_] I MAR 03 2026 I URINAL • WASHING MACHINE CONNECTION ? . WATER HEATER ALL TYPES WATER PIPING OTHER • INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES VINO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V 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 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 appllce9on 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 he In complrenca with all P nent provision of the Massachusetts State Plumbing Code and Chapter 142 of t e General Laws.D PLUMBER'S NAME -P ryrt,tJ� 'YY1' o Zayrte LICENSE# 9 go4 SIG URA MP tir JP❑ CORPORATION[}i 323 Q PARTNERSHIP 0# LLC❑# COMPANY NAME fill V 0 r n+ 1°-ft =n C' ADDRESS ii &0 wt p r� CITY W- JGi✓/6401.401 STATE -14 ZIP Q 2(01 3 TEL 7 74-i340� FAX CELL EMAIL Ga r . DM G 5► e cue I•Co v !aa 1- 7so Fsiv.r� C�(451-1 I -I- 5 0 = S`I Fri( 1 ne t,ummun weuttn uj irruasacnuseus Department of Industrial Accidents a =? PUN! Office of Investigations C. IMO : . ..._ Lafayette City Center * := ■= K 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AnDlicant,Information Please Print Legibly Name (Business/Organization/Individual): ,4// 1i7 Address: // City/State/Zip:/ 4 3 Phone #: —f5t(- 7 8'y Are y(91 an employe Check the appropriate box: Type of project (required): 1. 1 am a employer with ., 4• ❑ I am a general contractor and I 6. New construction employees (full and/or part-time).* have hired the sub-contractors 2. ❑ 1 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.t required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions 3. 0 1 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.❑ 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. Company Ensurancep y Name: i b -f IV'61W( / ( Expiration6 — I -- 2- G Policy # or Self ins. Lic. #: I �' �� Date: 2 lob Site Address: , l I c Ls City/State/Zip: N'z>/04 0 w 1"11 tittach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). .allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a -me 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 )f 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. r do hereby certify under the pains and penalties of perjury that the information provided above is true and correct: i� Date: - t� 2- >ignature: Nzyz. 2�_ y 'hone #: _ 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): 1DBoard of Health 2E1 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5l"Iumbing Inspector 6.0Other ._.. ALLPOINTO1 JHINDMAN AAWR0 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 12/1/2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONEACT World Insurance Associates,LLC PHONE (508)771 1 FAX 34 Main St. IArc,No.Eat): (Arc.No):(508 771.0663 West Yarmouth,MA 02673 Miss: INSURERS)AFFORDING COVERAGE NAIC! INSURER A:Progressive Casualty Insurance Company 24260 INSURED INSURER B ALL POINTS PLUMBING& HEATING INC INSURER c 11 CAMP STREET INSURER 0: WEST'YARMOUTH,MA 02673 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN8R I ADOUSUBR; POLICY EFF POLICY EXP TYPE OF INSURANCE DAD I YYYO• POLICY NUMBER NYM/DDIYYYYI EI MIDD/YYYIO LIMITS A X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE I 1,000,000 CLAIMS-MADE X I OCCUR PGR944556966 7f112025 717/2026 S DAMAEMISESlGE TO ERa ENTED50,000 PR I S MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY S GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS•COMP/OP AGO $ 2,000,000 OTHER: CO� s ED S AUTOMOBILE LIABILITY 1E2 accident) c ent INGLE LIMIT $ • ANY AUTO BODILY INJURY(Per person) $ OWNED r---1 SCHEDULED AUTOS ONLY 1 AUTOS s BODILY INJURY(Per accident) S _ AUTOS ONLY AUUTOS ONL (Per a YY I cddent)ERTY pAMAGE $ l $ UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED ! j RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMI3ER EXCLUDED? NIA andatory in ) E.L.DISEASE-EA EMPLOYEE$ IIf yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS, THER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Yarmouth Yam ACCORDANCE WITH THE POLICY PROVISIONS. 1146 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DATE(MM/DD/YYYY) ACOREP CERTIFICATE OF LIABILITY INSURANCE `,..------ 12/01/2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). - PRODUCER CONTACT NAME BIBERK PHONE Am,No.1.4:844-472-0967 FAX (AIC.Not: 203-654-3613 P.O. Box 113247 E-MAIL Stamford, CT 06911 ADDRESS: customerservice@biBERK.com INSURER(S)AFFORDING COVERAGE NAIC X INSURER A:Berkshire Hathaway Direct Insurance Company 10391 INSURED INSURER B: All Points Plumbing And Heating INSURER C: 11 Camp St INSURERD: West Yarmouth, MA 02673 INSURER Er INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR ---TYPE OF INSURANCE -_-- INSD WVD D POLICY NUMBER (MMIDY/YYYYI (MIDDM(YY)EFF POLICY EXP II LIMITS COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ 0 1 DAMAGE TO RENTED CLAIMS-MADE [ $ O. -I OCCUR PREMISES(Ea occurrence) MED EXP(Any one person) $ 0 PERSONAL&ADV INJURY $ 0 GEM.AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $ 0 POLICY J r 1 LOC PRODUCTS-COMP/OP AGG $ 0 OTHER: $ —__1 COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY _LEa accidnte $ II_ 1 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ J AUTOS ONLY AUTOS ONLY (Per accident) s UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED il RETENTION$ $ -7 WORKERS COMPENSATION X PER (AND EMPLOYERS LIABILITY OTH- STATUTE ER A OFFICER/MEMBER OE EXCLUDED?ECUTIVE NN NIA N9WC164143 06/18/2025 06/18/2026 EL EACH ACCIDENT $1OO,000 (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $100,000 j If yes,describe under 500 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ r Professional Liability (Errors & I Per Occurrence/ Omissions): Claims-Made Aggregate j DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE 7` "^ f - I ©1988-2015 ACORD CORPORATION. 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