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HomeMy WebLinkAboutBLDG-23-002834 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '" CITY IYARMOUTH MA DATE November 22,202; PERMIT# BLDG-23-002834 JOBSITE ADDRESS 123 BOG RD OWNER'S NAME DEMERS HOLLY JEAN TRS G OWNER ADDRESS DEMERS LAWRENCE D TRS 919 OLD BASS RIVER RD DENNIS MA 02660 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ID RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 0 OTHER OF INDEMNITY 0 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 (Robert Silva LICENSE# 120536 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: ROBERT N SILVA I ADDRESS. 15 STAYSAIL CIR, CITY IMARSTONS MLS STATE MA ZIP 026481879 TEL I FAX CELL EMAIL none MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK R " Y �(,' jl2Si^ yryt" MA. DATE PERMIT# Nod_8 �At DRESS: P . OWNER'S w# 1 i i i- C� OWNEP AD CRESS:�y-C6 TEL: FAX: Bann ORPARcjottOjAcy TYPE: COMMERCL L-a•'..., EDUCATIONAL ❑ RESIDENTIAL❑ "CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑ APPLIANCE81 FLOOR Bsmt 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 COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT tTEST UNIT HEATER t tj UNVENTED R EOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IXNO ❑ If you have checked Yam,please Indicate the type of coverage bychecldrig the appropriate box below. LIABILITY INSURANCE POLICY tom. OTHER TYPE INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER:tam 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 penult application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT hereby certify that all of the deter and kformation I have submitted(or ent d)regarding this plt Knowledge and that all plumbing work and instal tions performed under the pent*pent*Issued for this apa�t are willlue and a * ' whe ofmy provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. i onPertinent PLUMBER/GASFITTER NAME: R 0 k r r r `S ►I vM LICENSE# ZO S3�, SI NA RE COMPANY NAME: V 1 �, GI" lh j ADDRESS: Si f7 y S 13 l C k t CITY: jP1179-C CV ciA S V+'t .I (S STATE: PI l'9' ZIP: O Z 6 g FAX; TEL o 22 y Q E i Y 2 U � ELL: . .7 7,b 7d 2/ EMAIL MASTER❑ JOURNEYMmitt—CP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# • f.Lc❑# ' The Common wealth of Massachusetts —_, t � Department ofIndustrialAccidents —:1 t' y 1 Congress Street,Suite 100 Boston,MA 02114-2017 '`'�, . ' www mass.gov/diar Workers'Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Cheek the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.0.1 am a sole proprietor or partnership and have no employees working for me in 8. Remodelin any capacity.[No workers'comp.insurance required,] ❑ g 3.❑I am a homeowner doing all work myself 9. 0 Demolition ys [No workers'comp.insurance required.]t 4.❑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 insurer a or are sole 11.❑Electrical repairs or additions proprietors with no employees. 5.0 I am a generalcontractor and I have hired the sub-contractors listed on the attached sheet 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their rightof exemption14.❑Other 152,§1(4),and we have no 1 e MGL C. employees.[No workers'comp.insurance required.] *Airy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. fi 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 andjob 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 S1,500.00 and/or one-year imprisonment,as well as civil putties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this state..ent may rwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi,fy u>. - 1 - , ,..4 , , �� alfies f erjury that the information provided above is true and correct PP Signature: 2 Date: // Phone#: �()0 2 P 0 2 6 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.EIectrical Inspector 5.Plumbing Inspector 6.Other • Contact Person; Phone#: