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HomeMy WebLinkAboutBLSM-23-15 RECEIVED Commonwealth of Massachusetts r._"„,AUG Sheet Metal Permit BUILDING DEPARTMENT 06/16/2023 B �`f� -- Date: Permit# L Z `...) Estimated Job Cost: $25,377.00 Permit Fee: $50.00 V ... Plans Submitted: YES NO V Plans Reviewed: YES NO „-g Business License# 801 Applicant License# 4323 iBusiness Information: Property Owner/Job Location Information: Name: Coastal Mechanical Name: Donald Morrison tn Street: 22 Whites Path Street: 9 Millard Road City/Town: South Yarmouth, MA 02664 City/Town: South Yarmouth, MA 02664 1 Telephone: 508-737-8747 Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO V LW Staff Initial czy J-1 /M-1-unrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft./2-stories or less Residential: 1-2 family V Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. V over 10,000 sq. ft. Number of Stories: 1 Sheet metal work to be completed: New Work: V Renovation: HVAC V Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: 2- Zones 1-York Gas Furnace 1- York Condensing Unit Supplies and Returns INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes® No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ® Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 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 Owner's Agent By checking this box❑,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 sheet metal work and Installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ®Master //', Jl �®� Title ❑ Master-Restricted , W 6 dB'GT.(7 7 City/Town DJourneyperson Signature of Licensee Permit# ❑Journeyperson Restricted License Number: 4323 Fee$ ❑ Check at www.mass.qov/dpl Inspector Signature of Permit Approval . RECEIVED Commonwealth of Massachusetts rtiA'7ff—I-0/V AUG 14 2023 Sheet Metal Permit BUILDING DEPARTMENT Date: 06/16/2023 Permit# B - `TSB — `J Estimated Job Cost: $25,377.00 Permit Fee: $50.00 - Plans Submitted: YES NO V Plans Reviewed: YES NO C= Business License # 801 Applicant License# 4323 Business Information: Property Owner/Job Location Information: c) Name: Coastal Mechanical Name: Donald Morrison -"— Street: 22 Whites Path Street: 9 Millard Road City/Town: South Yarmouth, MA 02664 City/Town: South Yarmouth, MA 02664 L Telephone: 508-737-8747 Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO V LW Staff Initial Z) J-1 /M-1-unrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft./2-stories or less Residential: 1-2 family V Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. V over 10,000 sq. ft. Number of Stories: 1 Sheet metal work to be completed: New Work: V Renovation: HVAC V Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: 2- Zones 1-York Gas Furnace 1- York Condensing Unit Supplies and Returns INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes® No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ® Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 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 Owner's Agent By checking this boxO,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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ®Master //,, JlB �®� Title ID Master-Restricted � W 15 d 'GT.l7 City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: 4323 Fee$ ❑ Check at www.mass.gov/dpl Inspector Signature of Permit Approval ...... . 4--..., The Coinmonwealth of Massachusetts Department of Industriablecidetzts Office of Investigations _...-- `•-:- -7:ff.J.', 600 Washington Street Boston, MA 02111 -,,---7 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leuiblv Name ,BusInes.s, :itgia=22Ticit:M]r.:duz:i: Coastal mechanical_ _ Address: 22 Whites Path — City State/Zip: South Yarmouth, MA 02664 Phone ----,: 508-737-8747 _ -I Are you an employer? Check the appropriate box: 11 Type of project (required): I ::Z I urn a C111p10>CT with 40 4. E I urn a general contractor and 1 1 6, yr . New c.onstruction employees iyfuil and or part-time) ' have hired the sub-conuaciois cn c mg listed on the attached sheet. : 7' SIR x)d 1- 2.D 1 ara a sole prcprictor or panner- ship and have no employees These sub-contractors have S. 7 Demolition wotking for mc in any capacity. workers' comp, insurance 9, D Building addition [No workers' comp. insurance 5 E We arc a corporation and its • 10 E Electrical repairs or additions required] officers have exercised their 3.E I am a homeowner doing all work right of exemption per NIGL ILE Plumbing repairs or additions myself. [No workers' comp, C. 152,§1(4).and we have no 12.0 Roof repairs insurance required.] I employees. [No workers' 13,NfCrther Hvac comp. insurance tequired] 'ATI. applicant that checks box#1 must also till out the section below showing their workers'clAlipcostition policy information_ t Homeowners who submit this affidavit indicating thc!.are doing all work and then hoc outside contractors roi.t.sit submit a ne affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.ixilicy mfonnation. 1 am an employer that is providing workers'compensation insurance for my employees.. Below is the polity and job site information. Insurance Company Name: The Hilb Group of New England Policy For Self-ins. Lic. 5: WC 9099731 Expiration Date: 12/31/2023 Job Site Address: 9 Millard Road citvistatezip: South Yarmouth, MA 02664 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGI.c 152 can lead to the imposition of criminal penalties of a fine up to SI,500 00 and or one-year imprisonmenl as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to...":.50.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the()like of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and pcnalties of perjury that the information provided above is true and correct. Signature, 4251421%-a.m..2.44, Date. 06/15/2023 _ Phone::. 508-737-8747 .._ Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit # Issuing Authority(circle one): 1, Board of Health 2. Building Department 3.City(Town Clerk 4, Electrical inspector 5. Plumbing inspector b. Other Contact Person: _____ . Phone P: i .... OM ONWEALTH 'F M .SaCH T DIVISION OF OCCUPATIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE BUSINESS cc �z ROBERT D WOODBURY COASTAL PLUMBING AND HEATING LLC 299 WHITES PATH SOUTH YARMOUTH,MA 02664-1214 —31 801 03/0/12024 192570 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER I OMM S NWEALTH .F MAS A_H SE S DIVISION OF OCCUPATIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE MASTER-UNRESTRICTED Ct 2 ROBERT D WOODBURY 21 L'FRUEAN WAY; C ' SOUTH YARMOUTH,MA 02664-1671 4323 0 4128/2024 192770(^`y LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER _.._ _._...,_,:..,K-x-;..c. ::st- ,x: x-ArrIrM Vt. -v twitTit ' ` ACCPRE,f CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1/9/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: THE HILB GROUP OF NEW ENGLAND LLC PHONE 508-775-1620 FAX (A/C.No,Ext): (A/C,No): 973 IYANNOUGH ROAD E-MAIL ADDRESS: HYANNIS MA 02601 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: SELECTIVE INS CO OF SOUTH CAROLINA 19259 INSURED INSURER S: SELECTIVE INS CO OF SOUTH CAROLINA 19259 COASTAL PLUMBING & HEATING LLC INSURER C: SELECTIVE INS CO OF SOUTH CAROLINA 19259 21 FRUEAN WAY INSURER D: SOUTH YARMOUTH MA 02664-1690 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY)I(MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY X S 2573428 12/31/2022 12/31/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO(RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 B MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY X JECT X LOG PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ C AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 X A 9109656 12/31/2022 12/31/2023 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED AUTOS NON-OWNED PROPERTY DAMAGE ONLY X AUTOS ONLY (Per accident) B x UMBRELLA LIAB X OCCUR S 2573428 12/31/2022 12/31/2023 EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DED X I RETENTION$10,000 $ PER A WORKERS COMPENSATION WC 9099731 12/31/2022 12/31/2023 X STATUTE EERH AND EMPLOYERS'LIABILITY Y!N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) This Certificate of Liability Insurance was created by Selective on behalf of the agent. TOWN OF YARMOUTH is included as additional insured with respect to General Liability, Automobile as required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH 1146 ROUTE 28 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD