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Home My WebLink AboutG-18-7353 X1= 12 6l; 77q- ) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .51�, 'Ts—V CITY South Yarmouth MA DATE 6/26/2018 PERMIT# /340/1"-/7'Qt7770.9 JOBSITEADDRESS 72 Breezy Point Road OWNER'S NAME Schneider GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL El PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT OVEN ` , ' l V F- POOLHEATER ROOM!SPACE HEATER ROOF TOP UNIT . I JI 27 2L1 TEST UNIT HEATER i j . _L s / UWENTED ROOM HEATER ' WATER HEATER - " — --OTHER INSURANCE COVERAGE I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES ['NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY U(' OTHER TYPE 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 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 We 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-GASFITTERNAMEqie sw Andrew Levesque LICENSE# PL15162 GNATUg0 MP g MGF EX JP 0 JGF 0 LPG!0 CORPORATION 0# PARTNERSHIP 0# LLC g# 3944 COMPANY NAME Harwich Port Heating &Cooling LLC ADDRESS 461 Lower County Rd CITY Harwich Port STATE MA ZIP 02646 TEL_5O8-432-3959 FAX 508-432-6075 CELL 508-958-4874 EMAIL andy(a hphcinc.com 41; en Viliv fin 2-#41d-d 7t9' 97P --/Mal • `''� The Commonwealth of Massachusetts Department ofIndustrialAccidents • Office of Investigations fa, 600 Washington Street '" m Boston,MA. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Harwich Port Heating&Cooling LLC Address: 461 Lower County Road City/State/Zip: Harwich Port MA 02646 Phone#: 508-432-3959 Are you an employer?Check the appropriate box: 4. I am a general contractor and I Type of project(required): 1.[Yf I am a employer with 75 ❑ 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. Ea Remodeling ship and have no employees These sub-contractors have 8. []Demolition • working for me in any capacity. employees and have workers' 9. 12 Building addition [No workers' comp.insurance comp.insurance) required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.12 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.E Other HVAC comp.insurance required.] *Any applicant that checks box 41 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. tContractors 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: AmGuard Insurance Company Policy#or Self-ins.Lie.#: HAWC815956 Expiration Date: 10/26/2018 Job Site Address: 72 Breezy Point Road City/State/Zip: South Yarmouth, MA 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 MOL 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 rs and pena les of perjury that the information provided above is true and correct Signature: Date: 6/26/2018 Phone#: 508-432-3959 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#: