The URL can be used to link to this page

Home My WebLink AboutBLDG-23-003870 F � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY YARMOUTH MA DATE January 17,2023 PERMIT# BLDG-23-003870 JOBSITE ADDRESS 60 BROADWAY UNIT 19 OWNER'S NAME THE TIME SHARE ESTATE TRUST G OWNER ADDRESS 1 ARDELL RD BRONXVILLE NY 10708 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El 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 El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND El 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 LICENSE# 19681 SIGNATURE MP❑ MGF ❑ JP El JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbrideta7gmail.com MASSACHUSETTS UNIFORM APPLICATION FOR A ER IT TO PERFORM GAS FITTING WORK c cT1" 4-l'/7 O!/ NIA DATE �iZ /^ PERMIT# (U JOBSITE ADDRESS A• • ._.ice'/l rOctct .-7 OWNEWSNAME At.,Z,aidaj 26,1440 G OWNER ADDRESS V 512h &tvL.P'-S TEL . FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL PRI2 ❑ RESIDENTIAL( CLEARLY NEW:[ RENOVATION:0 REPLACEMENT; PLANS SUBMITTED: YES 0 NO VI APPLIANCES I- FLOORS-4 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 __ IVED POOL HEATER ROOM I SPACE HEATER ROOF TOP UNrr i JA I 13 2023 TEST / UNIT HEATER i UNVENTEDROOMH7=RATER 1 BUILDING DEPARTME-NT WATER HEATER OTHER ESTIMATED VALUE OF WORK: IIIIIIIIIII �a t I I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES [] NO Q I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITYINSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND [l OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance covers e r uired Cha Massachusetts General Laws,and that my signature on this9I by peer t 42 of the permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 I hereby certify that all of the details and information I have submitted or entered regarding this apprication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under thethis Q Q ( Massachusetts State Plumbingpermit issued for th t �O be In compliance with all Pertinent provision of the Chapter 142 of the General Laws. ...A.,.._.„ r_ PLUMBER-GASFITTER NAME 1 C 4L4�°C ,()3 I 1 LICENSE# SIGNATURE MP 0 MGF❑ JP[5- JGF 0 LPG!El CORPORATION❑# PARTNERSHIP 0# COMPANY NAME Pt t CA C/ti& P/ d/ tic ADDRESS /vi-/�J CITY f STATE v - - ZIP 7/ TEL X/01 ._ FAX CELL EMAIL /1 . NI ' b r Ii' - 3U c,Th The Commonwealth of Massachusetts ► "� i''1 Department of Industrial Accidents s'tiiEfl= •@ 1 Congress Street;Suite 100 1:41:f � Boston,MA 02114-2017 www mas&gov/dia %Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BB FILM)WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly • Name(Bnsiness/Organization/Individual): Address: • City/State/Zip: Phone#: Are you as employer?Check the appropriate box: Type of project(required): 1.0I ama employer with employees(full and/orparttime).* 7. ❑New construction 20 I am a sole proprietor orpartnership and have no employees working for roe in 8. ❑Remodeling . any capacity.[No workers'comp.insurance required.] 3. I am a homeowner all work [No worker!'co 9. ❑Demolition ❑ doingmyself. cop.insurance required.)t 4_0I am a homeowner and will be 10 El Building addition hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with employees. 12.['Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance* 6.0 We area corporation and its officers have criticised their right of exemption per MGL c. I4-QOther 152,§1(4),and we have no employees.[No workers'comp.inm,ranr.-required.] °Any applicant that checks box#1 mist also fill 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 shed showing the name of the sub-contactors and state whether or not those entities have employees.If the sub-contractors have employees,they must provide their workers'comp.policy number_ lam an employer that is providing workers'compensation insurance for my employees: Below is the policy and jab 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. . Ido 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 �4 Contact Person: Phone#: