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HomeMy WebLinkAboutG-14-621 A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Vtlil =tec CIN y/4 KM O IATH POV.T MA DATE Jc /7'43 PERMIT# 6/1/ — 4902i JOBSITEADDRESS, 1QQ RDurr-64 OWNER'S NAME f �/�/ILu4M ppf}�,'R7 1 G OWNER ADDRESS SAME T8-1•508'341' tried FAX TYPE OR OCCUPANCY TYPE COMMERCIALQ EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:El ./REPLACEMENT:L PLANS SUBMITTED: YESD NOD' APPLIANCES 7 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER . X0,40 W BOOSTER I� i- . � � � CONVERSION BURNER COOK STOVE —14PI +Wari I 1r DIRECT VENT HEATER Iiii$iiiizIi F7�_ lr I 1 1 FURNACE __ I_ GENERATOR ao KW ruksir1' ,1'i.' GRILLE r A' INFRARED HEATER giliggigi • , las LABORATORY COCKS MAKEUP AIR UNIT f l� _ I , '1 _ (— POOL HEATER : ROOM I SPACE HEATER 1 i ' , , P : ,i1 I l ' ROOF TOP UNIT . Win IMT INK isitarnimiunt i .1 UNIT HEATER111111S11111111111111111411111111111111111,TEST I i' i�R sis 2Z a ..-,� ' UNVENTED ROOM HEATER ' WATER HEATERil OTHER _! a! . 1 ` ` J INSURANCE COVERAGE 1 � '' 1)l' ',.�i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL., .142 '- YES E NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW BUILDING DEP?�• v r ._1 LIABILITY INSURANCE POLICY21/ OTHER TYPE INDEMNITY © ' 1".31--"" OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance.coverage required by Chapter 142 of the ,�,ctr Massachusetts General Laws,and that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are tnie,4 d accurate to the bes ••m$howle.ge and that all plumbing work and Installations performed under the permit Issued for this application will be In l- ce with al - 'flent now •n of . • Massachusetts State Plumbing Code and Chapter 142 of the General Laws. y/J. �r / PLUMBER-GASFITTER NAME „(k/4106/ /11 hsi-/AItGC LICENSE# �aY6S' "� ' SIGNA URE MP 12 MGF CI JP] JOE Q LPGI 0 CORPORATION E(# a F5 .1 PARTNERSHIP0# LLC©# COMPANY NAME: ,eHEpQ`%. ar,,,, )tim5_.INC.- ADDRESS /6* T,. .,77a5T_ .. . j CITY a, 1-05410 G.0 STATE MOLL ZIP 0..-24.4.0- TEL -031:-.9-1/407/F , FAX-%.1;f3 -j'5 10ELL6087 EMAIL .ifi0 � L/e// ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES It Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ '❑ FEE: $ PERMIT# PLAN REVIEW NOTES • _.z . ... • V• • - . • .• • . . tl . •• . . • • ' . • I d".1.tlf,fif.310V;3,„:.,•,emple3 at,r I? 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THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED • -'PRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. . ' ,DRTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 DDNTE:CT Rachelle Tucker, AAI, AIS NAM R.S. Gilmore Insurance Agency,_ Inc. IAHC NNo Ext!' (508)699-7511 IAIG Not; (508)695-3957 27. Elm St. . AIL ADDRess. rtucker@rsgilmore.com P. O. Box 126 INSURER(S)AFFORDING COVERAGE - NAIC R N. Attleboro MA 02761 INSURERAArbella Protection Insurance Co 41360 INSURED INSURER aArbella Mutual Insurance Co. 17000 Barros Companies, Inc. INSURER C: 164 East Street INSURERD: - INSURERE: Foxboro MA 02035 INSURER F: - - COVERAGES CERTIFICATE NUMBER:CL12121738527 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 INDICAI ED. 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 ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR_WVD POLICY NUMBER (MMVDDIYYYY) (MMIDDWYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY - PREMISES tEa occurrence) $ 300,000 A CLAIMS-MADE n OCCUR 8500041907 12/31/201212/31/2013 MED EXP(Any one person) $ ' 15,000 .. PERSONAL 8ADV INJURY $ 1,000,000 , GENERAL AGGREGATE _ $ 2,000,000 •� GEN'L AGGREGATE hLIMB APPLIES�IPER: PRODUCTS•COMP/OP AGO_ $ 2,000,000 • ' POLICY n F& ' I LOC - I LIITOMOBILE LIABILITY CO BINEDt SINGLE LIMIT-. $ 1.000,000 _ . . . - - BODILY INJURY(Per person) $ L — ALL ALL OWNED. SCHEDULED 86083400003 12/31/2012 12 31/2013 ' .X / BODILY INJURY(Per accident) $, • __ AUTOS _ AUTOS _ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ _ AUTOS (Per accident) INCLUDED Hired/borrowed $ 1,000,000 ' X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED X RETENTIONS 10,000 4600041908 12/31/2012 12/31/2013 $ WORKERS COMPENSATION WC STATU- OTH. AND EMPLOYERS'UABIIJTYY/N TORY LIMITS FR ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) • CERTIFICATE HOLDER CANCELLATION (508)398-0836 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Building Dept. - 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth, MA 02664 • Tim Gilmore/RTUCKE " 'A^- 7- T.2.—.r, ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005)01 The ACORD name and logo are registered marks of ACORD 1 CERTIFICATE OF LIABILITY INSURANCE DATE`"a"'°"'' 12/12/2012 co a 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: I£ the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject .o 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 R S Gilmore Insurance NAME: FAX Agency Inc (A/C. Na. E[n: (A/C. No): P 0 Box 126 PRSDlICER North Attleboro, MA 02761 CUSTOMER EDN. INSUREDS) MEMOIR,COVERAGE NAIL N IN''/KED INSURER A: A.I.M. Mutual Insurance Co 33758 Barros Companies Inc INSURER R: dba Barros Electric INSURER C: 164 East Street INSURER D, ' Foxboro, MA 02035 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 TEPMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - POLICY MISER POLICY EFF POLICY EXP ACA TYPE OF INSURANCE RenP/ml 003/S0/111-1003/S0/111-11LLYITS GENERAL LIABILITY EACH OC $ ❑.CMMERCIAL GENERAL LIARILITY DAMAGE TO TO RENTED $ D❑CLAIMS MME ❑OR"JR PREMISES Ma.aeeurteneel ' • HED E%P (Any one pxwn) $ ❑ PERSONAL a RCN WORT $ - . GYM I.A�e'TATE LIMIT APPLIES ERI OENLRAI.AGGREGATE S ❑POLICY ❑IR?IPIT❑Ery' PROOUTS-LOP/OP AGG $ . $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT lea Accident) $ •❑ALL 0.080 A'Th,t BODILY I WOAY Ipec pecten) $ ❑3CHEN:LLO N.It..S BODILY INJURY(Pee Accident, $ PROPERTY DAMAGE N.N.,":4 (pn acetxmt, 6 ❑PION-OWNED AUTOS •b 0 $ ❑IM,BRELLA LIAR ❑ O_CLR RACK OCCURRENCE $ []EXCESS LIM ❑ CLAIMS WE AGGREGATE $ 73IIIIA :TSULB E ❑RETENTION $ b WORKERS COMPENSATION - ® DTH- AND EMPLOYEES LIABILITY EY LmSTs ER THE PROPRIETOR/PARTNERS/ EXECUTIVE OFFICERS AHE E.L. CAEN ACCIDENT $ 500,000 A - ® lncl 0 r.Xcl 7025572012012 12/31/2012 12/31/2013 LL. DISEASE -POLICY LIMIT $ 500,000 F.L. DISEASE - EA EMPLOYEE $ 500,000 ' COMMENTS / DESCRIPTION OF OPERATIONS OR LOCATIONS: • CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH - %ETTN: DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE ': POLICY PROVISIONS. 1146 ROUTE 28 SOUTH YARMOUTH, MA 02669 AUTHORIZED REPRESENTATIVE -` L_ -- _ REPRESENTATIVE . - n0