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Home My WebLink AboutBLDP-26-240 M'A/SSACHUSSEETTS UNIFORM APPLICATION FOR A P RMIT 0 PERFORM PLUMBINGQ � WORKJ e/ CITY i _ _ /__g�/Y//J f MA DATE PERMIT#/x! u�—Z , /� JOBSITE ADDRESS /114i/2 Yt 2 ' OWNER'S NAME4 ,1 L/t,/, 5,_,-)P OWNER ADDRESS jj�// ' O TEL 7ri-7`S3�-AX TYPE OR OCCUPANCY TYPE COMMERCIAL X. EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW 0 RENOVATION:❑ REPLACEMENT:%IPLANS SUBMITTED:YES❑ NO FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 1 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/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK ^ � l\ E LAVATORY � r ROOF DRAIN - SHOWER STALL SERVICE I MOP SINK TOILET nSt125 DING DEPA tTM URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES Z WATER PIPING OTHER one. /4 Me`tG/li rl�n.4-i 0---^Q /1 iv) gi'l7`r+r�09i1 c. /L 2cT- - - - i INSURANCE COVERAGE: { I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES II NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY rg. 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 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement r SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT❑ LU 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 a General Laws./5��/ PLUMBERS NAME f I lCr4i e L 1NJ�r`l GG LIICENSSEES# SIGNATURE 60 MP❑ JPO CORPORATIONTI #POP'' PARTNERSHIP❑.# / C❑# 7� COMPANY N E/c rid, Ark !V— ADDRESS __/LJ __ / .'7 7 CITY lj S ti 4'/I/ S STATE ZIP Q t O/ TEL?7 Y r/4 //z FAX `` CELL EMAIL 5➢ ?y F/'./85 c_491`/CiPoontie-(L-(QM ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT # PLAN REVIEW NOTES ine t.ummunweuun of jnussucnuseus Department of Industrial Accidents Office of Investigations I'= fiLafayette City Center 2Avenue de Lafayette,Boston,MA 02111-1750 `=7,1:V www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ( ��1 �L II (.13 r 6=L Address: 3 Alv,e, f`.( q.l./i City/State/Zip: Phone#: Tj Y I Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I aim a employer with 4. 0 I am a general contractor and I employees(full and/or part-time).' have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. ❑Remodeling 2.[�I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. 0 Demolition workingforme in anycapacity. employees and have workers' P ty t 9. ❑Building addition [No workers'comp.insurance comp.insurance. required] 5.0 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 12.0 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. 'am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nformation. nsurance Company Name: 'olicy#or Self-ins.Lic.#: Expiration Date: ob Site Address: City/State/Zip: ,ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a ne 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 tvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided ab e is tru and correct mature: ' �_�� t Date: 3/ C 5—�O�( tone#: 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 20Building Department 31:City/Town Clerk 4.DElectrical Inspector 5DP)umbing inspector 6.0Other_ iniormauuii auu Etta L.B. ws chapter 152 requires all employers to provide.workers' compensation for their employees. Massachusetts General La p eq Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, P to Y express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more engaged in a enterprise, and including the legal representatives of a deceased employer,of the foregoingjointemployees. However the receiver or trustee of an individual, partnership, association or other legal entity, employing emp o ant of the a dwellinghouse having not more than three apartments and who resides therein, or thep dwellinghhouse owner of dwelling house of another who employs persons to do maintenance, construction or repair work on such er." appurtenant thereto shall not because of such employment be deemed to be an employ or on the grounds or building pp MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any • not produced acceptable evidence of compliance with the insurance coverage required." applicant who has 152, 25C 7 states "Neither the commonwealth nor any of its political subdivisions shall Additionally, MGL chapter § ( ) enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation nsation affidavit completely, by checking the boxes that apply to your situation and, if name(s), address(es) and phone number(s) along with their certificate(s) of necessary, supply sub-contractor(s) with no employees other than the insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) does have or partners, are not required to carry workers' compensation insurance. If an LLC or LLP 'al members be submitted to the Department of Industrial employees, a policy is required. Be advised that this affidavit may nand date the affidavit. The affidavit should Accidents for confirmation of insurance coverage. Also be sure to sin not the Department of be returned to the city or town that the application for the permit or license is being requested,to obtain a workers' Industrial Accidents. Should you have any questions regarding the law or if yourequired p compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavitcomplete is and printed legibly. The Department has provided a space at the bottom fill out in the event the Office of Investigations has to contact you regarding the applicant. of the affidavit for you to applicant fill in thepermit/license number which will be used as a reference number. In addition, an current Please be sure to given year, need only submit one affidavit indicating that must submit multiple permit/license applications in any � should write "all locations in (city or policy information (if necessary) and under "Job Site Address" the applicantthe cityor town may be provided to the p y ed or marked by town)." A copy of the affidavit that has been officially stamp permits or licenses. A new affidavit must be filled out each applicant as proof that a valid affidavit is on file for future ermit not related to any business or commercial venture year. Where a home owner or citizen is obtaining a license or p (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. thank you in advance for your cooperation and should you have any questions, The Office of Investigations would like to please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of industlial Accidents Office of investigations LafayetteCity Center, 2 Avenue de Lafayette Boston, MA 02] l 1-17 5° Tel. (617) 727-4900 or 1-877-MASSAFE Fax (617) 727-7749 1n l n