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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS Jjr /2"1f3/2c / i 7 (.lJ y 'OWNER'S NAME I .L�d OSO Gv#'C z I
GOWNER ADDRESS } ,,5%-7/71 _I TEL j�7 S'347FAX
TYPES OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL El RESIDENTIAL
PINT
CLEARLY NEW:I RENOVATION:11 REPLACEMENT:fl PLANS SUBMITTED: YES 0 NO[
APPLIANCES Z FLOORS-. BSM 1 2 3 4 5 6 7 8 I 9 10 11 12 13 14
BOILER , I'(
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BOOSTER ., = `
CONVERSION BURNER f ,1 ; lam: j; 1 w
COOK STOVE _ r 1 _ - 1
DIRECT VENT HEATER ; 1I 1 't ? 1, 11 I ' f 1
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INFRARED HEATER , —� f'--- IR I� + e J - - -
LABORATORY COCKS � t{ '
MAKEUP AIR UNIT i - _-' I °1
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POOL HEATER . ; L
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ROOM I SPACE HEATER '
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ROOF TOP UNIT 1i ii 1, ., - l
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- INSURANCE COVERAGE /
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1.40 L
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L_/ OTHER TYPE INDEMNITY I{{ 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 7 AGENT LI
SIGNATURE OF OWNER OR AGENT _
I hereby certify that all of the details and information I have submitted or entered regarding this application are tru d accurate to the bes).df m nowl ige
and that all plumbing work and installations performed under the permit issued for this application will be in compli ce with all,Pertinent rove n of/
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �` 44 //p�J}) f J i
PLUMBER-GASFITTER NAME , jy /}) ,,(,,�fjp,i,C LICENSE#I/a16Yj ' SI -LIRE
MP 11 MGF In JP 71 JGF El LPGI f1 i CORPORATION 171# d FaA 1 PARTNERSHIP f# I LLC n#
COMPANY NAME:]05/94y0,- tn,ivAt/,e5 j,e.,_, I ADDRESS!/�, .,y9-T yEJ, EE]-
CITY f'Oy,SO RG STATE Jn,14- ZIP o,43 i TEL ‘,3-0,3' j- -47/Y
FAX ya_ ql.,z I CELL � (EMAILI ,0' d U I
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No `✓Ffi 6204 c>rL,'E!/ edAr
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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Aco CERTIFICATE OF LIABILITY INSURANCE 12/15/20
r THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
/"`4, ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
SLOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
.EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: 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 FACT Jay Aguiar
R.S. Gilmore Insurance Agency, Inc. PtloriE Ee. (508)699-7511 FAX Nok(508)695-3957
27 Elm St. ADDRESS:A
P. O. Box 126 INSURERS)AFFORDING COVERAGE NAIC 0
N. Attleboro MA 02761 INsuRERAArbella Protection Insurance Co 41360
INSURED INsunERsArbella Mutual Insurance Co. 17000
Barros Companies, Inc. )NSURet c Hartford Ins Co 19682
164 East Street INSURERD:
INSURER E:
Foxboro MA 02035 INSURERF:
COVERAGES CERTIFICATE NUMBER:CL14121548097 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 REDU CED BY PAID CLAIMS.
dL R TYPE OF INSURANCE INSR�j M POLICY NUMBER (M6VDDIYYrn trammortyrn LIMITS
GIB ERAL LIABILITY EACH(YIN IRRENCE $ 1,000,000
DAMAGE RENTED
X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) S 300,000
A CLAIMS-MADE X OCCUR 8500041907 12/31/2014 12/31/2015 MED EXP(Any one person) s 15,000
PERSONAL 8 ADv INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN1 AGGREGATE UNIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000
n n
-i POLICY T LOC
2 AUTOMOBILE LIABILITY COMBINEDN SINGLE LIMIT Ea ) $ 1,000,000
ANY AUTO BODILY INJURY(Per person) $
—
ALLLOWNED X SCHEDULED 1020011223 12/31/2014 12/31/2015 BODILY INJURY(Per accident) S
X HIRED AUTOS X AUTOSWN�AUT
Per accidentl)ROPERTY DAMAGE S Included
Hircwroarowed $ 1,000,000
X UMBRELLA LAB X OAR EACH OCCURRENCE $ 1,000,000
A EXCESS LAB CLAMS-MADE AGGREGATE $ 1,000,000
DED X RETENTIONS 10,000 4600041908 12/31/2014 12/31/2015 $
C WOIBCERS COMPENSATION TO' R LIATU-MITS 0T
AND EMPLOYERS'UABIUTY
ANY PROPRIETOR/PARTNER/EXECUTNE ER
Y/N N/A E.L.EACH ACCIDENT $ 500,000
OFFIC(Mandatory In ERH)EXCLUDED? OBWECCS0341 12/31/2014 12/31/2015 E.L.DISEASE-EA EMPLOYEE $ 500,000
(Mandatory�NH)
If yes,desoibe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Addkbnal Remarks Schedule,B more apace 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
I Tim Gilmore/AMKAHA
ACORD 25(2010/05) ®1988-2010 ACORD CORPORATION. All rights reserved.
INS025 maim)a Tha A(_ARI1 name and Inn"am mania'sarnrl marl":of A(`ARrf