HomeMy WebLinkAboutBLDG-16-001818 `__--''` I JYLP _%=,GHU`.CI IS UNJrUYfYJr.rt'ul.r.Iww rvnr.ru-'tniI ice . �• -•••••• -- •_ • - •--•-•-
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JOESITE ADDRESS: L'I Ckk y' -`` 1 'N-- O1NI IEI'`S NAME 33 K''k (1-3^" J
Sor- -)
OWNER ADDRESS:_ TEL' ��
P OP. OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
P_ .
CLEARLY NEW:❑ RENOVATION:ION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
I APPLIANCES- FLOOR—, I asnt 1 1 2 3 I ^ 1 5 I o 1 7 8 1 9 I 10 1 11 1 12 1 13 1 14
I BOILER I I I I I I I I I
• BOOSTER I I I I I I I I I I
I CONVERSION BURNER I I I I I I I I I I
COOK STOVE I I I I I I I I I
I DIRECT VENT HEATER
DRYER 1 , I I I I I I
I FIREPLACE I i I I I I I I
FRYOLA l OR 1 1 I I I I I I
FURNACE I I 1 I I - I I
GENERATOR I I I I I I
I GRILLE I I I I I I
INFRARED HEATER I I I I I
I LABORATORY COCK I I I I I I I
I MJ'CEUP AIR UNIT I I I !
I °Val I I I I
POOL HEATER I I • I I I I
ROOM/SPACE HEATER I I I I '
ROOF TOP UNIT I I I I I
TEST I I I I I I I I
I UNIT HEATER I I I ! I I I I
I LAMENTED ROOM HEATER I I I I 1 I I I 1
I WATER HEAT. I I I I I I ' I I
I I I I I I I I- I
• ! - 1 I I I I I I I I
I 1 I I I I I
I INSURANCE COVERAGE
I have a current Iiabc rtv insurance poky or'rs substantial equivalent which mee the requireme=of NiGL Ch.1^.2 1 t'3 ❑ NO 0
If you have checked Yi S,please indicate-the type of coverage by cheating the approp1 box below.
LIABILITY INSURANCE POLICY ❑ OTHER-TYPE INDEMITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:1 am aware that the liicansee does not have the insurance coverage required by Chapter 142 of the
Wascachusets General Laws,and that icy signature on this permitapplicadon waives this requirement
CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNS.OR AGENT
hereby ceriiiy that all of the details and information I have subrrirted(or entered)regarding hits applcat;on are true and accurate tote best of my 1
Knowledge and that all plumbing work and installations performed under the permit issued for this applicalion villl be in compliance with all Pertinent
provision of the Wiassechusetis State Plumbing Code and Chapter'142 of the General Laws. _____ \ C—Q -__
PLUMB>�IGAS-I i I t-01AIt4E: '✓&Qs- P`'C f- LICENSE# c�`a.10'-9\ t SIGNATURE
COMPANY r"JE: 'e?i J` P' (`f c �) DRESS: 3 G 1)``'\ `.-~ t_
r03,60 : Sb -7
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CITY. /U� � +� I
TEL / DELL: �ll6 c�o`C�3 Li IEPJL' D D M u rr,da`' l f C Leo . Co• ...1,
MASTER❑ JOURNEYMAN LP INSTA I ❑ CORPORATION 0 PhiNE S t P 0- I,O
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• . Expiration _
iPTO Safety Insurance BUSINESSOWNERS DECLARATIONS
AUTO • HOME • BUSINESS Policy Period
Safety Insurance Company Policy Number From To
BMA0021888 05/14/2014 05/14/2015
12:01 A .Standard Time at the described location
Transaction - i
New Business Declarations
-*hied irtsu ed and Mailing Address Agent
DAVID MURRAY GERMANI INSURANCE AGENCY
36 TIDAL LN 908 MAIN ST
HYANNIS MA 02601 OSTERVILLE MA 02655
Telephone: 508-428-9194 61704
FORMS AND ENDORSEMENTS SCHEDULE
Coverage line Form Number Ed. Date Description
Businessowners BP0417 (01/96) Employment Related Practices Exclusion
Businessowners BP0108 (03/98) Massachusetts Changes
Businessowners BP0439 (01/96) Abuse or Molestation Exclusion
Businessowners BP0009 (01/97) Businessowners Common Policy Conditions
Businessowners SB0002 (11/99) Businessowners Special Prop. Cov. Form
Businessowners SB0006 (11/99) Businessowners Liability Coverage Form
Businessowners SB0518 (04/07) Asbestos or Other Respirable Dust Excl.
Businessowners IL0003 (04/98) Calculation of Premium
Businessowners SB0517 (04/07) Silica or Silica-Related Dust Excl.
Businessowners BP1004 (04/98) Excl of Certain Computer-Related Losses
Businessowners SB0542 (01/08) Excl of Pun. Damages Related to Terr.
Businessowners BP1005 (04/98) Excl-Year 2000 Computer Related Losses
Businessowners SB0514 (05/04) War Liability Exclusion
Businessowners SB0545 (04/07) Exclusion - Snow Removal Operations
Businessowners SB0576 (06/07) Limited Fungi or Bacteria Cov. (Property)
Businessowners SBM001 (06/01) Equipment Breakdown Endorsement
Businessowners SB0577 (11/02) Fungi or Bacteria Exclusion
Businessowners STN109 (01/08) Notice of Terrorism Insurance Coverage
Businessowners SB0701 (01/97) Amend. Of Policy Provisions-Contractors
Businessowners BP0703 (01/97) Property Damage Liab. Ded (Per Claim)
$250 Deductible
Businessowners SB0534 (11/02) Limited Exclusion of Acts of Terrorism
Premium has been waived for this coverage.
Businessowners BP0419 (06/89) Amend-Liquor Liab. Exclusion (Exception)
Countersigned By:
BPDEC2011
INSURED
� 0Safety Insurance BUSINESSOWNERS DECLARATIONS
AUTO • HOME • BUSINESS Policy Period
Safety Insurance Company Policy Number From To
BMA0021888 05/14/2014 05/14/2015
12:01 A .Standard Time at the described location
Tr`a nsaction
New Business Declarations
Named Insured and Mailing Address Agent
DAVID MURRAY GERMANI INSURANCE AGENCY
36 TIDAL LN 908 MAIN ST
HYANNIS MA 02601 OSTERVILLE MA 02655
Telephone: 508-428-9194 61704
Form of Business: INDIVIDUAL Type of Business: PLUMBING-RESIDENTIAL/DOMESTIC
DESCRIBED PREMISES
LOC BLDG ADDRESS AUTOMATIC INCREASE
001 36 TIDAL LN HYANNIS MA 02601 4%
PROPERTY
LOC BLDG COVERAGE VALUATION DEDUCTIBLE LIMIT OF
INSURANCE
001 001 Personal Property Replacement Cost $ 500 $ 10,000
Deductible shown above applies per any one occurrence
BUSINESS INCOME: Actual Loss Sustained Not Exceeding 12 Consecutive Months
LIABILITY AND MEDICAL EXPENSES
Except for Fire Legal Liability, each paid claim for the coverages listed reduces the amount of insurance we provide
during the applicable annual period. Please refer to Paragraph D.4. of the Businessowners Liability Coverage Form.
BUSINESS LIABILITY COVERAGE LIMITS OF INSURANCE
Liability $ 1, 0 00,0 0 o Per Occurrence
Medical Expenses $ l o,0 0 o Per Person
Fire Legal Liability $ l o o, o o o Any one Fire/Explosion
ADDITIONAL COVERAGES
Some property coverages are subject to deductibles specified in the policy forms.
Optional Property Coverage Description Limits of Insurance
LOC BLDG DESCRIBED COVERAGES
Optional Liability Coverage Description Limits of Insurance
Contractors-payroll $28,600
CHANGE IN PREMIUM: $ TOTAL PREMIUM: $ 1,559
BPDEC2011
INSURED