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HomeMy WebLinkAboutBLDP-25-955 eat ': iDEC 1 0 2025 1 . MAgSACHUSETTS.UNIFORM APPLICATION FOR A PERMIT To PERFORM PLUMBINGWORK .4. x )- • cm, /arrv1 c Jk ! MA'•coati ! * , tbla..:z�—95 - JOBSTIEAtDRESS I SI I1 54.4iipii Ave1 OWNER'S NA ErP,FQde R'vc.ke_t P ..OWNER ACOMESS . . . ._. I ' IF AI • TYPE OR WOUPANCY1YPE COLGERCIALO EcticATlaeu. Q RESIDENTIAL Er _ .• , CLEARLY I�I�vv:C.3 A EK REPIACtientEl POOMfiliMMErta VM.E1 MOO FIXTURES 1 FLOOR-. 1 us 1 1 1 2 S 4 1 a 6 7 1 4 i 1 .1 10: 1t j.12 4. 1 14 SA E i CROSS COIi NECTiON DEVICE i ., , ir ± i v 4 DEDICATED SPECIAL WASTE SYSTHrt - ` , It 1 r . . DEDICATED GAS/OLMA D SYSTEM F `. . A•.DEDICATED-GREASE SYSTEM - — I 4ir Agt if ei "-, DEXCATEDGRAY WATER SYSTEM , - - ''' ' 'DEDICATED WATER RECYCLE SYSTEM r a ■ r % 1 DISHWASHI2 .P 1 t ■ I • 1 DRINKING FOUNTAIN ' -r wr iti ' t -. .. 1 'FOOD DISPOSER - .1 i r AL - ` t FLOORI AREA DRAIN . 1 - 1 It. INTERCEPTOR(INTERIOR) i r ' Ai IL i • taTCHEA(SiNK a .. . • i ti i • LAVATORY *r i • j4 ROOF DRAIN r _�eraeearr •gor . . I i , . ' 4 SHOWER STALL 1 rit A AO ■r ■ . SERVICE/14F SINK - i A i i TOILET - 1 - . ' 1 in -•� • -a • i - 4f - ' i - III WASHING MACHINE CONNECTION I . . vii a - WATER HEATER At TYPES. low r , ilk 4 1 r `I - . , -witr '- t■ -1 l \ _ I . v , _ y i tee .`_ h.. ff-, `i ��. �. _ thanea��i itert x:;._.:!k Insurance policy arks s d equkaIent W MCD:m e uiqu em flt$O(M L 142. YE NO C3 •`rilINCHECSaiD YES,PLEASE INDICATE THE T!PE OF COVERAGE BY CHE4MMOBIIPPICONIATEBDi IIELOW LABILITY INSURANCE POUCYf• . OTHER TYPE OF tosiert 0 into Q •. .OWNER'S INSURANCE: Lam awaa°thst . rase > e etho. co iatteq Ilesd brawn* * . Massxchuaatts Goal ILaws,anda t my signature onlits pemdt appends*witylgthis requirement. SIGNATURE—.OF t NI ItoRAE T . f h eby oedltr ttad all of the detslk end Isdbnaadon I have sutra at entered regaling ttit fora a e-Oue enema i ithelyeeto>m knowledge andtstat plumbrro waicand Ir one{p Aaxeer1heneeanitweed for this aspendon vats In combo=with a6 Pertinent pmvtston oft* musette Stale Plumbing Code and Cl oil*:i Irene Laws. • r. *.4ryu►-atigrite_• PLUMBER'S NAME 1 Ni4 M t. e->G+ : • tuemsE#i tit't 1 Ion JP J Co> mot ' 33JPA rNER.stip 1)3 •,... . ..I c PANY NAME ALL to tad'H.SA c . 1 AtuREss, I t ';.V. , - . 14.3. rr+i"►ikt4. ,,. .. (,BTA'E F 7.23 l: 4%34011 1 is ; . -..f '" '. I . Ilt 80C 69h • a 1 ne c.ummunweuiin uj wiussucnuseus �y,� Department of Industrial Accidents H 'mums if , __ it1 Office of Investigations • — Lafayette City Center • -- 2 Avenue de Lafayette, Boston, MA 02111-1750 iNt www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):'// r p� � ��c Address: // City/State/Zip: /f/ ia,e,e M, 4.u.73 Phone #: 72 5/-f --f 7 ' Are you an em to e>tCheck the appropriate box: P YType of project (required): 1. I am a employer with 2- 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2. ❑ 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.l Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.EPlumbing 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. t 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. l am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. insurance Company Name: t) 1 Policy# or Self-ins. Lic. #: A a IVC ! 6,41 - 3 Expiration Date: 6 , 1 -2 fob Site Address: Ati City/State/Zip: Yaiiit/t i4'l1 tttach 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 -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 nvestigations 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. ;ignature: g/Nzyz..14 Date: .) Z I - 2 J '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 20 Building Department 30City/Town Clerk 4.1:1 Electrical Inspector 5Elumbing Inspector 6.0Other _ ACORD® DATE(MM/DDIYYYY) C 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 HONNo.Ext): 844-472-0967 _LAIC FAX,No): 203-654-3613 c.P.O. Box 113247 E-MAIL Stamford, CT 06911 ADDRESS: customerservice@biBERK.com INSURERISLAFFORDING COVERAGE NAIC# INSURER A: Berkshire Hathaway Direct Insurance Company 10391 INSURED INSURER B: All Points Plumbing And Heating INSURER C: 11 Camp St INSURER D: West Yarmouth, MA 0.2673 INSURERE: 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. INSR TYPE OF INSURANCE ADDL SUBR: /Y POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DDYYY) (MM/DDM(YY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 0 DAMAGE TO RENTED 11 CLAIMS-MADE 1 , OCCUR PREMISES(Ea occurrence) $ 0 MED EXP(Any one person) $ _ 0 PERSONAL&ADV INJURY $ 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 0 POLICY i PRO L JECT LOC PRODUCTS-COMP/OP AGG $ 0 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ace accident)ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS — — HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) i $ UMBRELLA LIAR OCCUR I I EACH OCCURRENCE $ CLAIMS-MADE EXCFSS LIAB AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER 1 OTH- AND EMPLOYERS LIABILITY STATUTE I ER N A ANYPROPRIETOR/PARTNE VEX ECUTIVE N N/A N9WC164143 06/18/2025 06/18/2026 E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUCED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes, describe under 500 000 DESCRIPTION OF OPERA"(IONS below + E.L DISEASE- POLICY LIMIT $ Professional Liability (Errors & j Per Occurrence/ Omissions): Claims-Made Aggregate 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 J- © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ALLPOINT01 JHINDMAN ,d►CORv° CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDmYY) 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 CONTACT NAME: World Insurance Associates,LLC PHONE FAX 34 Main St. (A/C,No,Ext):(508)771-8381 (A/C.No):(508)771-0663 West Yarmouth,MA 02673 ADDAIL RESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Progressive Casualty Insurance Company 24260 INSURED INSURER B: ALL POINTS PLUMBING& INSURER C: HEATING INC 11 CAMP STREET INSURER D: 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYY) IMM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR !PGR944556966 7/7/2025 7/7/2026 DAMAGES l:Eorg D 50,000 PREMISES(Ea occurtence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JEI f LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ D AUTOMOBILE LIABILITY (E aacad n)INGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED _ AUTEO�S ONLY _ AUTOS BODILYO INJURYD (Per accident) $ AUTOS ONLY AUUTOS ONLY (Perr a dent;AMAGE UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in ) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS,OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth ACCORDANCE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarrouth,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 3 r< �' `��' m yeq 'i i -',r.. '',- CI!)' f t. �,� 'a �y ..' _ z ]PP a.. ter` ,�f ai. - ,a J'b �R y3 , $ "^ ." • :` qo " a ,.. .1111111r/ < jil ilk (: 4s' -,m .ay..�yq.0 a v '4 r ' Y.I ,- 0 . 4N r"° c:i O ' �• s' r �Z ' . 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