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HomeMy WebLinkAboutBlds-21-004851 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -�1 CITY YARMOUTH MA DATE February 26,2021 PERMIT# BLDG-21-004851 II JOBSITE ADDRESS 45 SQUIRREL RUN OWNERS NAME BEMIS DIANE G OWNER ADDRESS 45 SQUIRREL RUN YARMOUTH PORT MA 02675-1835 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑ FIXTURES FLOORS—• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 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 ❑ 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 Leighton LICENSE# 16130 SIGNATURE MP© MGF 0 JP El JGF 0 LPG' El CORPORATION El# PARTNERSHIP 0# LLC ❑# COMPANY NAME: ANDREW R LEIGHTON ADDRESS. 20 Brewster Rd, CITY W Yarmouth STATE MA ZIP 026735706 TEL FAX CELL EMAIL halloilcompanyt7a gmail.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 (_o w MASSA .HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -V9- typto-roo Z"Lt �ocRY MA DATE .01 IIET y .2� PER # QC b G-z N9}�l l -oo JOBSITEADDF !SS f✓r u/r r L 3 vN .•OWNER'S NAME fig v I CS L ect_Y OWNER ADDR;SS 1' •• a TYPE OR TEL FAX PST OCCUPANCY1 'PE COMMERCIAL EDUCATIONAL RESIDENTIAL / CLEARLY NEW: / F NOVATION: REPLACEMENT: - PLANS SUBMITTED: YES NO V APPLIANCES Z FLOORS-' MA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER - CONVERSION BURNER On COOK STOVE DIRECT VENT HEATER DRYER _ _ __ FIREPLACE • FRYOLATOR - FURNACE _ GENERATOR . _ GRILLE MIME* INFRARED HEATERiMEN. NIB . _ LABORATORY COCKS MAKEUP AIR UNIT - _ i_ - OVEN - I� POOL POOL HEATER . . - ROOM!SPACE HEATER - . . - ROOF TOP UNIT TEST �� UNIT HEATER UNVENTED ROOM HEATER _ E ( �. WATER HEATER - _ OTHER INSURANCE COVERAGE I have a current liability insuranc policy or Its substantial equivalent which meets the requirements of MGL Ch.i42 YES 1/NO I IF YOU CHECKED YES,PLEASE IN ICATE THE TYPE OF COWRAGE BY CHEL'tONG THE APPROPRIATE gag(BELOW LIABILITY '+ISURANCE POLICY V/ OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Massachusetts General Laws,an;that my signature on this permit application wait this requirement CHECK ONE •; : OWNER AGENT SIGNATURE OF C TUNER OR AGM - I hereby certify thatall of the deter i Id hdueuadtttas I have submitted or mimosa regsofing this renacegon are. 1.,�L� or lm and that all munching erotic and Instal eons pew under Mai permit Issued for this a n wlfl ba In '-V- - mY ° � Maseeohuse8s State Plt Code Ind Chapter 142 of General Laws. % : j,� , ,�; • of the PLUMBER-GASFITTER NAME AN:1REW LEIGHTON UCENSE# 16130-M SIGNATURE MP ' MGF JP JOF LPGI CORPORATION + # 3734C PARTNERSHIP LLC # COMPANY NAME HALL OIL COME i,NY INC. ADDRESS 435 RT 134 CITY SOUTH DENNIS STATE MA ZIP 02850 FAX 508- 8 CELL TEL 508-398-3831 EMAIL h�yagma7.com Workers Compensation and Employers Liabill insurance Policy Insurer ID No(s):34363 MA Trade Self-insurance Group Inc. Carrier Policy#: Policy Period PO Box 859222-9222 021004100192121 01/01/2021 to 01/01/2022 Braintree,MA 02185-0000 Information Page Renewal Poi FEIN:042149852 Carver Prior Policy#: 0210041001921 item 1: Named Insured and Address Agency Hall Oil Company Inc. RogeraGray,Inc P.O.Box 1401 434 Route 134 South Dennis,MA 02680 South Dennis,MA 02660 Other Workplaces Not Shown Above: See Schedule of Operations Additional Named Insured: See Additional Named insureds if Applicable Type of Business: Corporation Federal ID#: 042149852 Risk ID: 000048146 NCCI/Bureau#:34363 Unemployment ID#: File#:021004100192121 Item 2.Policy Period The policy period is from 12:01 AM on 01/01/2021 to 12:01AM on 01/01/2022 based on the insured's mailing address time zone. Item 3.Coverage: A Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A The limits of our liability under Part Two are: Bodily Injury by Accident $1,000,000.00 each accident Bodily Injury by Disease $1,000,000.00 policy limit Bodily Injury by Disease $1,000,000.00 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15),WC000313(04/84),W0000408(/),WC000414A(01/19),WC0004226(01/15), NOE(01/01),WC200102(01/14), WC200301(04184),WC200302A(09/08),WC200303D(08/10),WC200306B(06/13),WC200405(06/01),WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit $549.00 $26,329.00 $26,329.00 $0.00 $0.00 Issuing Office: 35 Braintree Hif Office Park Ste 206 Date Printed: Countersigned by: p2'i Braintree MA 02185-0000 01-07-2021 Form#WC000001 C (Ed.) ®Copyright 2013 National Council on Compsnset$on Insurance,Inc.AN Rights Reserved. Page 1 of