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HomeMy WebLinkAboutBldg-21-001229 t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Titt7.7_,5 CITY WEST YARMOUTH MA DATE 9/4/2020 PERMIT# BL. —c I- 9 JOBSITEADDRESS 19ANCHORAGE LANE OWNER'S NAME MCKENZIE GOWNER ADDRESS TEL 508-989-4687 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IXI PRINT CLEARLY NEW:® RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0 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 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED 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 [ENO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 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 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. -149 i�.I -i2.r f ./ie- PLUMBER-GASFITTER NAME Andrew Levesque LICENSE# pL15162 NATUSV MP g MGF M' JP❑ JGF❑ LPG!❑ 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 508-432-3959_ FAX 508-432-6075 CELL 508-958-4874 EMAIL andy@hphcinc.00r SIP 0 S 2°5 e # S 1 The Commonwealth of Massachusetts i t— Department of Industrial Accidents 1 r WM=, Office ofInvestigations 1 gi•;, 600 Washington Street 4.= ' 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 t City/State/Zip: Harwich Port MA 02646 Phone#: 508-432-3959 Are you an employer?Check the appropriate box: Type of project(required): 1,f J am a employer with 75 4. [II I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 New construction i 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. 0 Demolition 1 workingfor me incapacity. employees and have workers' any pa tY 9. 2 Building addition [No workers'comp.insurance comp.insurance.t required.] - 5. ❑ We are a corporation and its 10.g Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.Ga Plumbing repairs or additions 1 myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs II insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.I Other HVAC 1 1 comp.insurance required.] *Any applicant that checks box#1 must also liii 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. - I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Selective Insurance Company of South Carolina Policy#or Self-ins.Lie.#: WC9059813 Expiration Date: 10126/2020 Job Site Address: 19 ANCHORAGE LANE City/State/Zip: WEST YARMOUTH, MA 02673 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 i Investigations of the fDIA for insuranc coverage verification. 11 Ida hereby cert frf td' a d penalties of perjury that the information provided above is true and correct. Signature: • Date: 9/4/2020 • f[ Phone#: 508-432-3959 Official use only. Do not write in this area,to be completed by city or town official. i City or Town: Permit/License#/ j Issuing Authority(circle one): If 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other . Contact Person: Phone#: .. li. i 1 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK --i1;:s=ki,,,,,, ti yg ' CITY YARMOUTH MA DATE September 09,202 PERMIT# BLDG 21 001229 JOBSITE ADDRESS 19&21 ANCHORAGE LN OWNER'S NAME MCKENZIE WILLIAM A G OWNER ADDRESS P 0 BOX 791 WEST DENNIS MA 02670-0791 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 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 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ 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. SIGNATURE OF OWNER OR AGENT 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 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-GASFITTER NAME ANDREW LEVESQUE LICENSE# 15162 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: HARWICHPORT HEATING AND COOLING ADDRESS. 461 LOWER COUNTY ROAD, CITY HARWICHPORT STATE MA ZIP 02646 TEL FAX CELL EMAIL andy@hphcllc.com a ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No RG 'iI i f 242 0 Cf THIS APPLICATION SERVES AS THE PERMIT ❑ El ? /L�'LI CYS FEE: $ PERMIT# PLAN REVIEW NOTES