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Home My WebLink AboutBLDP-26-398 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK a any j • CITY/TOWN Yo1-1nioinN MA DATE 1'" 1 r -Zt; PERMIT# P Z(o✓�0 JOBSITEADDRESS 9 /1V-i-e I OD& C. YAa.A- OWNER'S NAME Albulrira/I P OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL E. PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:a PLANS SUBMITTED:YES❑ NO 0 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 RECEIVED URINAL • WASHING MACHINE CONNECTION • MAY 2 2C26 WATER HEATER ALL TYPES • WATER PIPING BUILDING DErMI'TMENT OTHER By II2NUGATrp►r -Pie 1 d INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES L' NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 5 OTHER TYPE OF INDEMNITY 0 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 /3R/nn/ /ncr✓7 LICENSE# /1 770 SIGNATURE MP 2' JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME WL r.w*w v / olt6/.41 c 0,rrr.a ADDRESS /S J11 r•4 d/,a"(E I./ CITY /4a4rurcH STATE/KA ZIP O2c. 5 TEL 54Y-'7'rC-414,.4V FAX CELL EMAIL a. 4 6 Of.4 rL .Co,.t C K.* 349 COMMONWEALTH OF MASSACHUSETTS Division of Occupational Licensure To update your information, fix incorrect information, renew your Board of State Examiners of Plumbers andf-As, license or get help with your license, visit http://massy ov/DPL. Gas Fitters This license is subject to Massachusetts General Laws and regulations. Your license is a privilege and cannot be lent or Plumbing Master � 9 p g 4" assigned to any person or entity under penalty of law. Keep a Brian Kliment paper or digital copy of this license on your person or posted as 15 JULIA GRACE LANE, HARWICH, `, required by law and/or regulations. Massachusetts, 02645111 EXPIRATION LICENSE NUMBER 5/1/2028 11770-PL-M Sarah R. Wilkinson, Commissioner SERIAL NUMBER r 234878 MASS.GOV/DPL COMMONWEALTH OF MASSACHUSETTS Division of Occupational Licensure To update your information,fix incorrect information,renew your Board of State Examiners of Plumbers and '` license or get help with your license,visit http://mass.gov/DPL. Gas Fitters This license Is subject to Massachusetts General Laws and Plumbing Journeyman I k regulations. Your license is a privilege and cannot be lent or assigned to any person or entity under penalty of law.Keep a Ot- Brian Kliment paper or digital copy of this license on your person or posted as it 15 JULIA GRACE LANE,HARWICH, f required by law and/or regulations. Massachusetts,02645 EXPIRATION LICENSE NUMBER Sarah R.Wilkinson,Commissioner OilI .iJ 8 22758-PL-J SERIAL NUMBER 283492 MASS.GOV/DPL The Commonwealth of Massachusetts �=a= Department of Industrial Accidents , Office of Investigations Lafayette City Center =• 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): /34-i,ii✓/CL�rn wr Address: /S. Jo e.,n City/State/Zip: NA N /rfA o244S Phone#: $'6g^77G-.tt4t44o Are you an employer?Check the appropriate box: contractor and I Type of project(required): 1.❑ I am a employer with 4. ❑I am a general employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.Q I 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 tY• 9. ❑Building addition [No workers'comp.insurance comp.insurance.: required.] 5.❑We are a corporation and its 10.❑Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their MaPlumbing 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 subcontractors 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:/13X'acwn're40 Policy#or Self-ins.Lic.#: Expiration Date: DC T-ZG Job Site Address: 9 '"'/ '- 124 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: /J � Date: /0A1 '2-2G Phone#: So 8-7'74.—'Y00/0 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 20 Building Department 31:City/Town Clerk 4.1:Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: