HomeMy WebLinkAboutBldsm-20-005060 SHEET METAL PERMIT
Commonwealth of Massachusetts
•.;� ::° ,/ Town of Yarmouth Building Department
1146 Route 28, South Yarmouth, MA 02664-4492
Date: 3 -13 -Lo Permit#: 8Z.6S/1- 420 _00 6,(,
Estimated Job Cost: $ / o o o Permit Fee: $
Plans Submitted: YES Plans Reviewed: YES/NO
Business License# 31 S Application License# S/' 8'
Business Information Property Owner/Job Location Information
Name: VA km. 4l S .►s LLC Name: Q., rr., h1.11s Ge I�' CL �ous�
Street: Po so, 7.97 Street:4 zs t+s+
City/Town: Arte.Adalc vvi A City/Town: w, Ys% 4
Telephone: S'l�g _ g gg - 17 yr Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES/NO Staff Initial:
J-1/M-1 unrestricted license
J-2/M-2 restricted to dwellings 3 stories or less and commercial up to 10,000 sq. ft./2
stories or less
Residential: 1-2 family_ Multi-family Condo/Townhouses_ Other
Commercial: Office Retail Industrial_Educational Institutional_Other>
Square Footage: under 10,000 sq. ft. .over 10,000 sq. ft._Number of stories: a
Sheet metal work to be completed:
New work_ Renovation: '4 HVAC: X Metal Watershed Roofing:_
Kitchen Exhaust System:_Metal Chimney/Vents:_Air Balancing:_
Provide detailed description of work to be dons 4►.,j(t
RtPlhcecL '1 • A S, ts. c...,t•.emscr`4
it Coet.AheL4-ca �e Py.�s�-�. �..►ck suealc
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of
M.G.L. Ch. 112 Yes X No
If you have checked Yam, indicate the type of coverage by checking the appropriate box below:
A 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 112 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 Owner's Agent
By checking here4 ,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 sheet metal work and installation performed under the permit issued for this application
will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General laws.
Inspections shall be called for prior to insulation installation.
Duct inspection required prior to insulation installation: Yes No
Progress Inspections
Date: Comments:
Final Inspections
Date: Comments:
Type of license:
By: Master C►�_
Title: Master-Restricted 1`Signature of Licensee 1`
City/Town: Journeyperson
Permit#: Journeyperson-Restricted License Number: KG Fro
Fee: $ Check at www.mass.gov/dpl
T Inspector Signature of Permit'I`
of Permit Approval
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BOARD OF
PLUMBERS AND GAS7•ITTERS SHEET METAL WORKERS
FOLLOWING LICE.
I SSL T'rI ISSUES THE FOLLOWING LICENSE F:S P NSE
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REGISTERED PLUMBING CORP - La
, P BUSINESS CC
PAUL M GENS PAUL M GENS a
z
9?•11G MECHANICAL SYSTEMS LLC -,
-, - PMG MECHANICAL SYSTEMS LLC !
11 JAN SEBASTIAN DRIVE PO BOX
797
UNIT i2 FORESTDALE,MA 02644 o
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SANDWICH,MA 02563
3329 05/01/2020 4.14-3925
_—, 315 04/07/2021 612974
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PLUMBERS AND GASFITTERS SHEET METAL WORKERS
ISSUES THr.-.. FOLLOWING LICENSE
ISSUES THE FOLLOWING LICENSE
MASTER PLUMBER 5' MASTER-UNRESTRICTED
P: =
PAUL M GENS
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5..
PO BOX 797 s... •,
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FORESTDALE,MA 02644-0704 • E: ---
FORESTDALE,MA 02544-0704
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PLUMBERS AND GASFITTERS
ISSUES THE.FOLLOWING LICENSE
JOURNEYMAN PLUMBER :-..•
7.."--..1 ",--- _._
T.•
?AUL Nri GENS -7: --7--
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PO;sox 797 PAUL GENS
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FORESTDALE.MA 02644-0704 ., ----.
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FORESTOALE NIA 02644
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24299 05/0112020 449094 fr. -." ./....,
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• PAUL
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PAUL GENS
5 ANCHOR DR
FORESTDALE MA 02644
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-'at Wor;:,:Seaty Certificets Program
as'e:: red Id.) the .•-_,,,dai Author;:y 'rlayr,:.^,J..7-s,v...':-."cr..
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Catfcate n•...,m'de7: 0365705 •
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'_'`e f:TN The Commonwealth of Massachusetts
Department of Industrial Accidents
/ , N Office of Investigations
IT; 1
k S r , '; 600 Washington Street
`,A `744 Boston,MA 02111
{. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): pmg mechanical systems Ilc
Address: po box 797
City/State/Zip: forestdale ma 0244 Phone#: 508 888 1 745
Are you an employer?Check the appropriate box: Type of project(required):
1. ✓ I am a employer with 4 4. I am a general contractor and I 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. employees and have workers' 9. Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. We are a corporation and its 10. Electrical repairs or additions
officers have exercised their 11.! Plumbing repairs or additions
3. I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL 12. Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13. Other N V A t S � N���l
comp. insurance required.]
*Any applicant that checks box#1 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.
: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.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: travelers
Policy#or Self-ins.Lic.#: UB4K061104 Expiration Date: 3-15-20
Job Site Address: 635 w yarmouth rd City/State/Zip: 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 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 u the pains and penalties of perjury that the information provided above is true and correct
Signature: t--....-- Date:3-13-20
Phone#: 508 888 1745
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#:
A�oe CERTIFICATE OF LIABILITY INSURANCE DATE(MwoonvrY)
4/4/2019
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: 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 �T CT Select Department
Eastern Insurance Group LLC PHONE (800)572-4538 .No):7S1-586-8244
233 Nest Central Stxiss
y ,selectwork@easterninaurance.com
INSURERS)AFFORDING COVERAGE NAIC#
Natick MA 01760 INSURER A:Charter Oaks Fire 25615
INSURED INsuRERa:Travelers Inc of America 25666
Ping Mechanical Systems LLC INsuRERc:Travelers Indemnity Co 25658
P.O. Box 797 INSURERD:TraV Ind of CT 25682
INSURER E:
Forestdale MA 02644 INSURER F:
COVERAGES CERTIFICATE NUMBER4aster 19-20 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 REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS
LTR SAD W MI
VD POLICY NUMBER IMDDIYYYYI (MMIDOIYYYYI
X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000
AGE TO
A CLAIMS-MADE X OCCUR PREMISES(EaEcTED occiarence) $ 300,000
680157511816 3/15/2019 3/15/2020 MED EXP(Any one person) $ 5,000
PERSONAL 8 ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
POLICY X jEC LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: Project Aggregate $ 10,000,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
B — ANY AUTO BODILY INJURY(Per person) $
ALOOWNED X SSCHHEDEDULED RA159511298 3/15/2019 3/15/2020 BODILY INJURY(Per accident) $
AU
NON-OWNED PROPERTY DAMAGE $
X HIRED AUTOS X AUTOS (Per accident)
$
X UMBRELLA'JAB X OCCUR EACH OCCURRENCE S 3,000,000
C EXCESS LIAB CMS MADE AGGREGATE $ 3,000,000
DE0 X RETENTIONS 5,000 CUP8587N106 3/15/2019 3/15/2020 $
WORKERS COMPENSATION X SPTA UTE OT-
ER
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N/A EL EACH ACCIDENT $ 1,000,000
OFFICD (Mandatory In ERH)EXCLUDED? N OB4X061104 3/15/2019 3/15/2020 E.L.DISFASF-EA EMPLOYEE $ 1,000,000
(Mandatory NH)
If describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached I more apace Is required)
Plumbing, Heating and HVAC Contractor.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
John Koegel/KSMIT
01988.2014 ACORD CORPORATION. All rights reserved
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INSO25(mum%