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Home My WebLink AboutBLDG-22-002547 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tailI CITY YARMOUTH MA DATE November 03,202:PERMIT# BLDG-22-002547 JOBSITE ADDRESS 21 TRUMAN LN OWNER'S NAME DONAIS JEFFREY A G OWNER ADDRESS DONAIS MARGARET E 56 RIDGE RD SOUTH HADLEY MA 01075 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL. 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 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/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 0 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 Robert Brodie LICENSE# 30565 SIGNATURE MP 0 MGF 0 JP 0 JGF 0 LPG' 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ROBERT D BRODIE ADDRESS. 184 VILLAGE LN, CITY WELLFLEET STATE MA ZIP 026678119 TEL FAX CELL EMAIL northcoastph(@,orotonmail.com S31ON M3IA321 NVld #11M3d $:33d ❑ ❑ 111NH3d 3H1 SV S3ALI3S NOI1v011ddtl SIHl oN seA S310N NO1103dSNI 1VNId AINO 3Sl 210133dSNI 210d 39Vd SIR! S3LON NO1103dSNI SV9 HOfO21 mtutiVEDI NOV 0 3 2021 MAt4V Q M APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK CITY: ii#V744 MA. DATE: !J )7_/ PERMIT# 2`t - Z'C JOBSITE ADDRESS: i-/ /1/7L1 Nn4K I H OWNERS NAME: De kW:5 GOWNER ADDRESS: 5•44-of TEL:41/3•-'S3/-rlf: AX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(J�' PRINT CLEARLY NEW:❑ RENOVATION:K REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-1 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 1 GENERATOR GRILLE VI INFRARED HEATER �L LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER .1 ROOF TOP UNIT TEST UNIT HEATER i� UNVENTED ROOM 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 XNO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 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 corn Ilia ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERIGASFITTERNAME:_ ZI2/ �✓edet" LICENSE# :42,5"T SIr.,TURE COMPANY NAME: 6 6477 co,4 ., ADDRESS: r?O• ?0 y 7 V 9 CITY: STATE: __Nig ZIP:4::202/ 71 FAX: TEL:Se)(5- +/,30—2 2 L/3 CELL: EMAIL: n$9 rf lip•cs r ft'h Its!y0✓D + +oft'). Cyl.s� MASTER❑ JOURNEYMAN, LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# _ . The Commonwealth of Massachusetts y_..,- 1� t I Department of Industrial Accidents 1011� 1 Congress Street, Suite 100 =art_! ° Boston, MA 02114-2017 "A* 4 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): &RAN f ?ytJ.4., Address: 4�. !3a le- —2 yy City/State/Zip:41. / 'iwie4 /I1/1 Phone#: 1-0 $ —6' So — 2 Zy 3 Are you an employer?Check e appropriate box: ' Type of project(required): I.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. am a sole proprietor or partnership and have no employees working for me in 8.A Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 I: Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must 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 suck $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 and job 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signatur : ��i�� Date: // 3/2—/ Phone#: f,a— 6 a -2-'2 `,/.3 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#: