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HomeMy WebLinkAboutBLDG-21-000751 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK :kartCITY YARMOUTH MA DATE August 16,2020 PERMIT# BLDG-21-000751 • JOBSITE ADDRESS 53 RAYMOND AVE OWNER'S NAME DONNA BIGELOW G OWNER ADDRESS 53 RAYMOND AVE SOUTH YARMOUTH 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL El CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO 111 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 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 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 (David Houde I LICENSE# 116673 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPGI 0 CORPORATION❑#I I PARTNERSHIP ❑#I ILLC ❑#I I COMPANY NAME: 'MCDONNELL MECHANISCAL SERVICES, I ADDRESS. 179 School Street, CITY (Wet Dennis I STATE IMa I ZIP 102670 I TEL I I FAX 1 I CELL 1 I EMAIL IbarbaraL mcdonnellmechanical.com I ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ Ne. ////G` G? FEE: $ PERMIT# 1 PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Y «_ CITY S Yarmouth MA DATE 8/11/20 _� j ' �. PERMIT# L ✓-/-00d 9 )/ JOBSITE ADDRESS 53 Raymond Ave OWNER'S NAME Donna Bigelow GOWNER ADDRESS 53 Raymond Ave, S Yarmouth, MA 02664 TEL 804-769-2804 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES El NO APPLIANCES 7 FLOORS-0 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 X GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ® NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE 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. CHECK ONE ONLY: OWNER El AGENT El 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 compl e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME David D Houde LICENSE# 16673 SIGNATURE MP El MGF El JP❑ JGF❑ LPG'❑ CORPORATION®# 4333 PARTNERSHIP❑# LLC❑# COMPANY NAME McDonnell Mechanical Services, Inc ADDRESS 79 School Street CITY W Dennis STATE MA ZIP 02670 TEL 508-394-0005 FAX 508-394-5050 CELL 508-246-3152 EMAIL barbara@mcdonnellmechanical.com Fold.Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE ce, •r PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED PLUMBING CORP DAVID D HOUDE MCDONNELL MECHANICAL SERVICES, INC. w;>' 79 SCHOOL STREET W. DENNIS,MA 02670 4333 05/01/2022 812241 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER ARI® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/25/2020 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 ACT Nancy Soule,CISR Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX (A/C,No,Ext): (A/C,No 973 lyannough Road E-MAIL nsoule@doins.com ) ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Tri-State Insurance Co.of Minnesota 31003 INSURED INSURER B; Acadia Insurance Company 31325 McDonnell Mechanical Services,Inc. INSURER C: Twin City Fire Insurance Company 29459 79 School Street INSURER D INSURER E: West Dennis MA 02670-2445 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 AWL SUHIF POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ CLAIMS-MADE X OCCUR DAMAGE I 0 HEN ihD 300,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A ADV0395010-19 05/19/2020 05/19/2021 1,000,000 PERSONAL&ADVINJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 XPRO- JECT X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ea accident) BODILY INJURY(Per person) $ B OWNED SCHEDULED ADA0395008-20 AUTOS ONLY X A TOS 05/19/2020 05/19/2021 BODILY INJURY(Per accident) $ X Net� NON-OWNED PROPERTY DAMAGE AUTOS ONLY /� AUTOS ONLY (Per accident) $ X UMBRELLA LIAR X OCCUR 2,000,000 EACH OCCURRENCE $ B EXCESS LIAB CLAIMS-MADE CUA5250858-14 05/19/2020 05/19/2021 $ , , 2000000 AGGREGATE DED X RETENTION$ 0 WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY X PER OTH- Y/N STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE 500,000 OFFICER/MEMBER EXCLUDED? N N/A 08WECCF1837 06/06/2020 06/06/2021 E.L.EACH ACCIDENT $ (Mandatory in NH) L. 500,000 If yes,describe under E. DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements.Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended thecoverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN McDonnell Mechanical Services,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 79 School Street AUTHORIZED REPRESENTATIVE West Dennis MA 02670 ©r �/'�C—�---• I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ E>6> t(/i4 o FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �>e - CITY YARMOUTH MA DATE August 16,2020 PERMIT# BLDG-21-000751 JOBSITE ADDRESS 53 RAYMOND AVE OWNER'S NAME DONNA BIGELOW G OWNER ADDRESS 53 RAYMOND AVE SOUTH YARMOUTH 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATI ON:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO 111 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 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 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 David Houde LICENSE# 16673 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: MCDONNELL MECHANISCAL SERVICES, ADDRESS. 79 School Street, CITY Wet Dennis STATE Ma ZIP 02670 TEL FAX CELL EMAIL barbara(a,mcdonnellmechanical.com