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HomeMy WebLinkAboutBLDG-21-004228 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 �1 CITY YARMOUTH MA DATE January 29,2021 PERMIT# BLDG-21-004228 l JOBSITE ADDRESS 308 ROUTE 6A OWNER'S NAME KAREN STEUER G OWNER ADDRESS 308 ROUTE 6A YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: 0 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 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 © NO 0 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 Francois Paravisini LICENSE# 15211 SIGNATURE MP Q MGF❑JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Francois Paravisini ADDRESS. PO Box 2585, CITY Orleans STATE MA ZIP 026536585 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No �t Jj Olt /J21/2 J CFS THIS APPLICATION SERVES AS THE PERMIT El El FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING T1-._ . ft WORK aid CITY __ ___. . _.-_- - - _..-__ _ ____ - -1 r _ �� . r✓Y t j..f' 1 MA DATE t-t15 _Y_ I PERMIT # ,061, c�-/ 02 '4 JJTaf.__- - - _---- __ __._.. _ . 3 .----- . ... AL.---._.._JOBSITE ADDRESS! l OWNER'S NAME >7 � _ _ GOWNER ADDRESS - ' _-- FAX ----- : TEI 7 � � 1 TYPE OR OCCUPANCY TYPE COMMERCIAL �' PRINT [. EDUCATIONAL RESIDENTIAL CLEARLY NEW:[/t1 RENOVATION: [ ' REPLACEMENT: L ' PLANS SUBMITTED: YES L i NO n APPLIANCES Z FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .... .-.7.; - . ..__ _ _ ..�. _ -1,---., - __.... _..._. ... . ,...-�_ - BOOSTER = 77:1-_-LI..t__ _ �� '---1 ___. _-- �� '. . -_ ��,,� .� - ~—`�. �. r�; � . �._._...� CONVERSION BURNER _1_ . -� _..__ - i COOKSTOVE __-._ ._-.iiC :Iw. . _.._.�._ ._..-�.� .. __._� w -=: -� . _ TEI *ow-,a_.. • .., ,_....• . DIRECT VENT HEATER :_ _�. _ a,. .�:----� - I _ 4 DRYER = -_-- _ FIREPLACE -_.-__ ii -_.._,_� : - __._.-.. _ �- _ � � �- ��. �_ . ,...____ .....,__ FURNACE -- .;.- _ - � . � � �-- "7_1_7 �. -�. ��. .. �. � GENERATOR -...a,- ..� ::_�._�.�4� _. .-. -..�� - �+ ..-_ .. 1 _� .:.w...��. .� � _.� �` .w _ , � � GRILLE ;-1. _ - �_` . Y INFRARED HEATER _ `- In --�_. 1 LABORATORY COCKS WM IllitWITM, - -I I MAKEUP AIR UNIT iM J I OVEN ---- - , - - 1. M_ __._ ..-_,__ _..- -- - I �...____ ______ .a . POOL HEATER � _. __ ROOM / SPACE HEATER :,-- ___ ._ _ _ . -= -;; _ �- ____ _ . . � _ _ 71, ROOF TOP ---�; . r� L.. 1 y . +. _.�_ _ i. ;, - fir ._ _ , �- � 0 UNIT t TEST -_ _ I _-- - - -- __ . — -_ _';_._-_ ��_ I .-.� UNVENTED ROOM HEATER _ �� _1;_, _ ,j w � � 11 .::::—.1 WATER HEATER . _ _� �,� -- - OTHER `i -.wr.wa.,wu.rrar,,..... .+i __ _. _t.':.._�1J 1 , TTi1. _'i a-S -s-—'s _ �1 • _ J.__ ___,___,' __lir __ _: �. INSURANCE COVERAGE JA f � 1 d2 1 ', I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 14 . YES jio, ,i. I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW g U I t.D I N G [� pA R T M t 6y LIABILITY INSURANCE POLICY _� OTHER TYPE INDEMNITY LTi BOND L C 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 ir. I AGENT i 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 cgcrapitance wi. h all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f PLUMBER-GASFITTER �NAME rail,�,,K Ji._C►r�t�-s-�+�.�_ -j LICENSE #ri,,sal/ f SIGNATURE MP [j�'' MGF ; ,, J JP JGF! ` LPGI ` CORPORATION J/'�# r - -- P I ;L 0 _� PARTNERSHIP I.._�#� LLC : # ._ COMPANY NAME: � ._ C - - _ _-� ADDRESS ! _ - - ..� . .- - � ._. __ .- - -1 sitt./ (0 0022 1 P. CITY � � i f .C.t4eLSi STATE ZIP TEL' 7 1 �Jd9aFAX : CELLi -EMAIL - -.._ _. _.. ..TTT] .."... r � p/cøizJye6, � vailb f�. • 7 D ,per t ' The Commonwealth of Massachusetts IIC/ Department oflndustrialAccidentr r a _ I=a Office of Investigations 600 Washington Street ��,,� $ostan,MA 02111 www.rnassgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information • Please Print Legibly Name(Businesss//OOrganization/Individual): Ay ' I CO Address: I g MCi i c) c+y� City/State/Zip:1j01't•1,nS /7P046S Phone#l: ( a o Are you an employer?Check the( appropriate box: Type of project(required): I.Uri am a employer with > 4.Q I am a general contractor and I __/ employees(full and/or part-time).' have hired the sub contractors 6. ❑New construction2.❑I am a sole proprietor or partner- 7.on the attached sheet 7. ❑Remodeling ship and have no employees These sub contractors have S. El Demolition working for me in any capacity. -- - [No workers'comp.insurance required.] employees and have workers' 9. Buildingaddition comp.insurance.= 5.0 We are a corporation and its 10.0 Electrical repairs or additions 3.Q I am a homeowner doing all work officers have exercised their I1.�Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]► c.152,§1(4),and we have no employees.[No workers' 13.0 Other ( comp.insurance required] *Any applicant that checks box Ill must also En out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating'they arc doing all work and then hire outside contractors must submit i now affidavit indicating such ZCantraetms that cheek this box most 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 it the policy and job site Information. Insurance Company Name: e1 f 6;c1.[/'/j/t_,iT/(,,'ri( /��J(J, i Policy 1/or Self-ins.Lic.#:: 1 I Ci(6 . Expiration Date: / —/—a( Job Site Address: QZJ/ City/State/Zip: Yc 16 Pori 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 MGL c.152 can lead to the imposition of criminal penalties of 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 S250.00 a day against the violator.'Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce ti er the pains and penalties ofperjury that the information provided above is true and correct. •Sian lure: �+ Date: /—I S--d/ Phone#l: 1 O�_�5 S [ 1.1 Official use only. Do not write in this area,to be completed by city or town official .- , City or Town: Perm it/Licanse k Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone if: llham ••••••••4 .. • . _ 71. , , . . • • . - ;- • _ _ - . _ 7 _ ‘•. , • -•- •