Loading...
HomeMy WebLinkAboutBldp-21-000190 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY IYARMOUTH I MA DATE (July 14,2020 I PERMIT# BLDP-21-000190 JOBSITE ADDRESS 137 SALT MARSH LN I OWNER'S NAME DUNNING JOHN J TRS G OWNER ADDRESS IFOLEY JANICE 35 MENOTOMY RD ARLINGTON MA 02476 I TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT PLANS SUBMITTED: YES 0 NO 0 CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:10 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 I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 0 OTHER OF INDEMNITY 0 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 (Michael Mcbride I LICENSE# 119681 I SIGNATURE MP❑ MGF 0 JP© JGF 0 LPG! ❑ CORPORATION❑#I I PARTNERSHIP ❑# LLC ❑# COMPANY NAME: IMICHAEL R MCBRIDE I ADDRESS. 19 Rustic Drive, CITY (West Yarmouth I STATE MA ZIP 102673 I TEL I FAX I I CELL I I EMAIL Istinger.mcbride@gmail.com I ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El CI FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PE MI TO PERFORM GAS FITTING WORK �`_ /1v MA DATE PERMIT# &D P i-06 /90 CITY l� U. y� 1l C.)� JOBSITE ADDRESS 7 5q/� A f'j 1, r�� OWNER'S NAME J ,e71 iw re) (-S1/71 GOWNER ADDRESS 7 ' TEL Z,5-2 ”3 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[fj, PRINT CLEARLY NEW: .--RENOVATION:❑ Elif EMENT ] PLANS SUBMITTED: YES❑ NOI APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 1.3 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 ►r r� - - ROOF TOP UNIT _ _TEST . UNIT HEATER JUG 1 4 2020 rr pi UNVENTED ROOM HEATER Q•Bin niA, ���ti,r ` r WATER HEATER t h11 1 7. OTHER _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES P,Z1 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [14 . 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 ❑ 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 IA C OP I- IL- M f ,u LICENSE#] ( I SIGNATURE MP❑ MGF El JP® JGF❑ LPGI❑ CORPORATION❑# l (PARTNERSHIP❑#Pre P LLC❑# COMPANY NAM R r i p-4-- t - ADDRESS ' 2 v 5 J Z C ,in l / l 1/4'r. CITY W 4 f' Al()l) STATE V A' ZIP 3 TEL 7 V V M 7/Z z- FAX CELL EMAIL D A e) .M c:.Qf L 69,0 fe j",d4--) L . Co M • The Commonwealth of Massachusetts Department of Industrial Accidents eEtitl_ 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH[lilt PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/lndivichu 1): 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 2.0I 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. ❑Demolition 10 Q Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.1D I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.: 13.11Roof repairs 6.0 We area corporation and its officers have exeicised their right of exemption per MGL c. 14.Q 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 whp 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: — 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 perjwy 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#: