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Home My WebLink AboutBldg-22-002544 • MASSACHUSETTS UNIFORM APPLICATION FOR A PE M TO PERFORM GAS FITTING WORK CITY Lid. Y/. r,f}'j. (J j4 MA DATE PERMIT# BI D P off/-b3,6 /90 JOBSITE ADDRESS 3,1--'5 f d"! CI I, m OWNER'S NAME jail Fa (1�/ GOWNER ADDRESS l TEL , C&S 3 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: Ind, RENOVATION:❑ R[2. MENT PLANS SUBMITTED: YES❑ NOK APPLIANCES 7 FLOORS-I 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 j • ROOF TOP UNIT }TET :. f • UNIT HEATER f JU� 1 4 )Op r t� UNVENTED ROOM HEATER oyUi �N _ f 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 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [XL. OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAVER: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 ❑ AGENT ❑ 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 ertinent provision of the Massachusetts State Plumbing Code and hapter 142 of the General Laws. PLUMBER-GASFITTER NAME M C UP L M ijio LICENSE# -r4 7 I SIGNATURE ria MP❑ MGF❑ JP J JGF❑ LPG!❑ CORPORATION ❑# PARTNERSHIP❑#Pre P. LLC❑# COMPANY NAMfiNk f j tako �4 t" ADDRESS C 2() 5 riC l j I' CITY �J 61,(` !v v UPI STATE ZIP I5 7,(40 73 TEL 7 V V/e) FAX GEL EMAIL /10eP.n^c..gr i I� l . con, v Ll a " The Commonwealth of Massachusetts *_" ft Department of IndustrialAccidents =,= ?= 1 Congress Street, Suite 100 1:1= Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electririans/Plumbers. TO BE FILED WITH Ili PERMITTING AUTHORITY. Applicant Information Please Print Lesibly • Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2:❑I am a sole proprietor or partnership and have no employees working for me in 8 ❑Remodeling any.capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.::I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof repairs These sub-contractors have employees and have workers'comp.insurancet ❑ ep 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners whQ submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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#: Y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • e 7 CITY YARMOUTH MA DATE November 03,2021 PERMIT# BLDG-22-002544 JOBSITE ADDRESS 2 SACHEM PATH OWNER'S NAME Regina O'Keefe G OWNER ADDRESS 2 SACHEM PATH WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS--0 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 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER • ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:piping 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 Sean Oleary LICENSE# 3957 SIGNATURE MP❑ MGF ❑ JP❑ JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: SEAN F OLEARY ADDRESS. 2 FABYAN RD, CITY PLYMOUTH STATE MA ZIP 023602390 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE:$ PERMIT# PLAN REVIEW NOTES $tioO,bD '` ;CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK s CITY" '' /9/?MO} H MP DATE PERMIT* zz — 2S`►'� OV { CI: E,ADD'ES5 �J‘.. . C`([-f/V� (� l l`�i 4. OWNERS NAME I�L.6 Y4- (��,J �.- - INC; whu1 11 1 SS PC; N t� � TEL /J �-,INT u UPAIVCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: [ 1 PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-4 6slu1 1 2 3 4 5 6 7 S 9 10 11 12 '13 14. BOILER BOOSTER — CONVERSION BURNER COOK STOVE DIRECT VENT HEATER � i DRYER `-� FIREPLACE FRYOLATOR / I FURNACE - GENERATOR GRILLE INFRARED HEATER - LABORATORY COCKS ---! MAKEUP AIR UNIT . _� OVEN POOL HEATER L_; ROOM I SPACE HEATER ' ROOF TOP UNIT TEST UNIT HEATER — ( _ l 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 I VI NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E 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 • I • Massachusetts General Laws,and that my signature on this permit application waives this requirement, • CHECK ONE ON : OWNER ❑ AGENT ❑ • SIGNATURE OF OWNER OR AGENT rk I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurate to the st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in cam with all P • rovision of the Li Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE#lei C.1 SI ` TU E MP ❑ IMF❑ JP ❑ JGF LPGI❑ CORPORATION❑ t PARTNERSHIP❑# LLC❑# COMPANY NAME $i^4-t f- 6 tisc-Atey ADDRESS c2 FAB Y A-1 el)CITY 11—ki MOU TT I - STATE rV l/4- r ZIP C-Ya3666 TEL -'7 5-7- 'L/ 00 FAX CELL EMAIL A9aW6G r/ rA Ca>CP4 Ale r ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPEUI ION NOTES Yes No • THIS APPLICATION SERVES AS THE PERMIT • ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES • • • • • • • • • "-----,----L, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - s w' CITY YARMOUTH MA DATE July 14,2020 PERMIT# BLDP-21-000190 OWNER'S NAME DUNNING JOHN J TRS JOBSITE ADDRESS 137 SALT MARSH LN G OWNER ADDRESS FOLEY JANICE 35 MENOTOMY RD ARLINGTON MA 02476 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 12 PRINT PLANS SUBMITTED: YES ❑ NO❑ CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:Ill FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 aUILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR • FURNACE • GENERATOR - INFRAE RED HEATER 1111- LABORATORY COCKS MEM _____ - 1111 OVEN IIIIIIIIIII-_ ____ POOL HEATER 1111 111111 al ROOM I SPACE HEATER _ __-__________ Ell - ROOF TOP UNIT ______ITETEI NMI_____ __ IIIII MI Ell UNVENTED ROOM HEATER 1 ___-__1111111 __ - NI OTHER ___ OTHER DESCRIPTION: INSURANCE COVERAGE: YES ❑ NO 0 I have a current Iiabil' insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOWBOND 0 LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does o e not s this requirement. insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application SIGNATURE OF OWNER OR AGENT application are true and accurate to the best of my knowledge this ap will in etrue and with all Pertinent provisionmy of e and I hereby certify that all of the details and information I have submitted or entered regarding this er the Massachusetts State Plumbing'Code and Chapteions performed2 ofdthe General'Lawt s for this application 19681 SIGNATURE Michael Mcbride LICENSE# TUC ❑#� PLUMBER-GAS FITTER NAME CORPORATION 0# PARTNERSHIP ❑# MP 0 MGF 0 JP JGF 0 LPGI 0 ADDRESS. 9 Rustic Drive, COMPANY NAME: MICHAEL R MCBRIDE OM ZIP 02673 TEL STATE CITY West Yarmouth FAX CELL EMAIL stinger.mcbrideggmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT FEE:$ PERMIT# PLAN REVIEW NOTES