Fill - Free fillable Plumbing Permit Application (Town of Belmont) PDF form

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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK

CITY/TOWN __________________________________ MA DATE ______________________ PERMIT # ___________________

JOBSITE ADDRESS ____________________________________________ OWNER’S NAME ______________________________

OWNER ADDRESS ____________________________________________ TEL _____________________ FAX _________________

OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL

NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO

FIXTURES  FLOOR

BSM

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

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 NO

IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW

LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 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 ______________________________________ LICENSE #_____________ SIGNATURE

MP JP CORPORATION # __________________ PARTNERSHIP #__________________ LLC #__________________

COMPANY NAME _____________________________________________ ADDRESS ____________________________________________________

CITY ______________________________________ STATE ______ ZIP ______________________ TEL ______________________________

FAX _________________________ CELL _________________________ EMAIL _____________________________________________________

WATER METER

ROUGH PLUMBING INSPECTION NOTES

_________________________________________________

BELOW FOR OFFICE USE ONLY

Yes No

THIS APPLICATION SERVES AS THE PERMIT

FEE: $________________ PERMIT # ___________________

PLAN REVIEW NOTES

____________________________________________________

FINAL INSPECTION NOTES

________________________________________________

The Commonwealth of Massachusetts

Department of Industrial Accidents

Office of Investigations

1 Congress Street, Suite 100

Boston, MA 02114-2017

www.mass.gov/dia

Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers

Applicant Information Please Print Legibly

Name (Business/Organization/Individual):_________________________________________________ _

Address:__________________________________________________________________________

City/State/Zip:_____________________________ Phone #:________________________________

*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.

I 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. Lic. #:__________________________________________ 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 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: Date:

Phone #:

Official use only. Do not write in this area, to be 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 #:_________________________________

Type of project (required):

6. New construction

7. Remodeling

8. Demolition

9. Building addition

10. Electrical repairs or additions

11. Plumbing repairs or additions

12. Roof repairs

13. Other____________________

1. I am a employer with _________

employees (full and/or part-time).*

2. I am a sole proprietor or partner-

ship and have no employees

working for me in any capacity.

[No workers’ comp. insurance

required.]

3. I am a homeowner doing all work

myself. [No workers’ comp.

insurance required.]

†

Are you an employer? Check the appropriate box:

4. I am a general contractor and I

have hired the sub-contractors

listed on the attached sheet.

These sub-contractors have

employees and have workers’

comp. insurance.

‡

5. We are a corporation and its

officers have exercised their

right of exemption per MGL

c. 152, §1(4), and we have no

employees. [No workers’

comp. insurance required.]

Information and Instructions

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 been presented to the 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 phone number(s) along with their 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 LLC or LLP does have

employees, a policy is required. Be advised that this affidavit may be submitted to 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 (if necessary) 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. A new 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 Commonwealth of Massachusetts

Department of Industrial Accidents

Office of Investigations

1 Congress Street, Suite 100

Boston, MA 02114-2017

Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE

Fax # 617-727-7749

www.mass.gov/dia

Revised 7-2013

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