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HomeMy WebLinkAboutPlumbing Permit MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY MA DATE r _L� _( PERMIT# JOBSITE ADDRESS LN OWNER'S NAME OWNER ADDRESS Q TEL FAX -Ji TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: ©4 PLANS SUBMITTED: YES, NODI FIXTURES'l 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 I _. __1 _ ( J I ! .._ -__ ((- ._I f __...._.II ! ._I DEDICATED GREASE SYSTEM _1j __i DEDICATED GRAY WATER SYSTEM I _ [ _._, ______# ( _.__.__I l—.-_J I=== DEDICATED WATER RECYCLE SYSTEM I _._..1 _ { 1 � DISHWASHER �-�1 __ __.._I DRINKING FOUNTAIN =:J1 i ...__ I .__._I __ .__1 __...._I I -------- FOOD DISPOSER FLOOR/AREADRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK =1 __I _( .( _____I ED __-_f LAVATORY —ALL-1 __. _� _.__.T1 _--� --..____1 _--.—,I _—_� __ __( ..__._J -I .__._,=...1 __._I —___( ROOF DRAIN _ ! _._.1 I ..__.__! I __..._.l _ra ._..... _) .__.._� _..__ ,I .__.._ ! .__. . I ( _j � _-1 SHOWER STALLI SERVICE/MOP SINK _ _..I ___.__J ___.___I _._..__! _____I ._..__I ._...___.J ..___,_) _._..__I __.___1 .---_._I TOILET _ I _ I __- __D URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES J=== a _ I .._. r LJ J WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESfn NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY-{` OTHER TYPE OF INDEMNITY Q BOND Ej 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 El AGENT IF-11 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 - _ tom-)_ LICENSE# I SIGNATURE MP D JP[R CORPORATION M# PARTNERSHIP Ell# _ LLC _# _ _ _j COMPANY NAME O[ —_f j,,'urlO°a ,v i ADDRESS j ter' j --- -- -I CITY f - ZIP ( c ------- -—STATE TEL T) ` ---- FAX CELL���EMAIL _ ROUGH PLUMBING INSPEC ON NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No 5 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth ofMassachusetts Department oflndustriglAccidents Office of Investigations 600 Washington. Street Boston,MA.02111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit:Builders/Contractors/Electricians/Plulmbers Applicant Information Please Print Legibly Name(Business/OrgadzatiorAndividual): C111 c l c Address: City/State/Zip: b4n� ��— n)g10l Phone#: `9`61 — I Are you an employer?Check the appropriate box: Typo of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. fgNew construction employees(fall and/or part-time).* have hired the sub-contractors 2.P1 am a sole proprietor or p artner- listed on the attached sheet.+ 'Z• E]Remodeling ship and'have no employees 'These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.F1 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.P"Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12,[]Roofrepairs insurance .re uiredemployees.[No workers' required.) 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 a're doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X 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 requiredunder Section 25A ofMGL o. 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. Bo advised that a copy of this statement maybe forwarded to the Office of 'Investigations of the DTA for insurance coverage verification. X do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. - 19 Signature Date � � g Phone# � Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: Information and Instructiolm­8 Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, 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 of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." 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 applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresentedtothe contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phonenumber(s)along withtheir certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LL C or LLP does have employees,a policy is required. Be advised that this affidavit may be submittedto the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' 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 affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Cornx aORMall of Massachusetts Depafteut af,fadustx%al Accidents Offzge ofIuyestigatio1w 600 0 Wasbiugtou.Street Boston?MA Q2X 1 Z TQI,#6X7-727-4900 ext4Q6-ox x-g77,�MASSAFF, Revised 5-26-05 Fax#617-727-7749