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HomeMy WebLinkAboutBLDG-21-002070 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tol, BLDG-21-002070CITY YARMOUTH MA DATE October 19,2020 PERMIT# JOBSITE ADDRESS 53 WEST WOODS VILLAGE OWNER'S NAME VAUGHAN DAVID W TRS G OWNER ADDRESS VAUGHAN LINDA A 4665 WINGED FOOT CT APT 201 NAPLES FL 34112-7969 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 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 Gary Famigliette LICENSE# 10191 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: GARY FAMIGLIETTE ADDRESS. 67 MAPLE AVE, CITY HYANNIS STATE MA ZIP 026014403 TEL FAX CELL EMAIL S31ON M3IA3a NVld #LIWa3d $:33d ❑ ❑ 1II J83d 3H1 SV S3AH3S NOI1VOIlddV SIHI oN SOA S31ON NOI103dSNI 1VNId AINO 3Sf1 a0103dSNl 2:10d 3OVd SIH1 S310N NOI103dSNI SV0 HOf1021 -r— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 727,1 CITY Gt rr►'1(>cc . _.__.. MA DATE PERMIT# . G /-b O JOBSITE ADDRESS t • -(OWNER'S NAME s7 P, ��� P GOWNER ADDRESS .3 L )PS^>- t.C-9oD ST -1 TEL.5:;- '13-(e sic y 1FAX- 1 TYPE OR OCCUPANCY TYPE COMMERCIAL:,J EDUCATIONAL PRINT J RESIDENTIAL" CLEARLY NEW:,J RENOVATION:J REPLACEMENT: _I PLANS SUBMITTED: YES J NQ+ APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 J BOILER ___J___I_J-J_J___J__I.__I-___I____I___ I__1 J__ _J J BOOSTER ___I___I I I I I_J___.1-J_____1- . J__I J I_I CONVERSION BURNER -J_ J __I I_J I. I 1__I I_I__I_I_J - _ COOK STOVE 1 I - I J 1- . (_I-)_1__J_J___I___J DIRECT VENT HEATER ____I I _1, I i__I I I=j I_J_J_I DRYER- -J-J J )--�,; . . .I-J.-J-J I I _ I-J_.___I-J FIREPLACE ,. �l-J_J,l �-1 -J I I I i-1�-J FRYOLATOR I i__I—J.-1 .-. I I _I. I _,I _ _i -J—J 11) FURNACE _�J__J-_1_—J —J II I I '-—' --_._J ._.�I—J I GENERATOR i I i I 1 I I Ii_� I - GRILLE , __i_J__J,_. _J J I_ _J_j'__J _.J _1_I.__.J___J_J INFRARED HEATER -J-J _-I_____1 _ . .1.__ ;-_ I_I___J;_____I -J I-_I_� LABORATORY COCKS I _ I I._...._I__I____I__J:____I_....__I___I_I ___J_J arap MAKEUP AIR UNIT _..._.I ' bOVEN I.....___i. i 1 I____!___J__.._I ____J_ _�i I__J__.J i POOL HEATER _J I____1 I,____I_._-__I____J .. 1 I___J_____I___ 1.• 1-_I_I ROOM/SPACE HEATER _..I . !___I _ 1 i,_._ # i___I i ! __ 1 i-__- I !I 1 ROOF TOP UNIT _I I I 1 { 1 I 1 1 I_J I J TEST ..i ! I i I i--__.i i . i i_ 1- - 1 1 UNIT HEATER ! t ___1_ 1 I___1 _I I 1_-I___J I UNVENTED ROOM HEATER _I ___J l _�I _______i _J_J___�—J_.____J __ _ i ___.J WATER HEATER ---- ------_..._ I I 1 -I �._ __J I I I I I _OTHER..', _. __ . _. 1 1_ __. I ____I__ i I I ______J—1 I i I I I __J .. I i _ I _J_._I I ____I -1_._J 1._.J� -.J L I_._J__J____I__i__._J--- !__-_J__.1 I_I, _ -i J___ I_ 1_.-._.1 i- -I I 1_'_ ' ! 1 1 J 1. I _ i 1 INSURANCE COVERAGE _ CI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO J I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY NiCI OTHER TYPE INDEMNITY ..__I J BOND L i 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 11 AGENT _._J 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 accurat the best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in compile with al e !he provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME,oc,✓� ,,,,,I•e, J.e .j--{ I LICENSE#J DI Si E SIGNATURE MP 54 MGF._:_.1 JP J JGF,11 LPGI J CORPORATION J# 1 PARTNERSHIP_I# i LLC J#' COMPANY NAME :PIA vvt C c� j ADDRESS (o-] 4,10tw U P CITY yC 1 n,S ___I STATE et (ZIP ©2Qri ' 4'/ "TEL -7 2 s's d r-FAX 1 CELL • IEMAIL' v�cp (2Tc,,,Ic,ts . vOQ 7 I .5f2- ,432S GIG-irr, 2 6V ' . .. ... . . . .. ., ..• •.. - . . . . . ... . . • • - •....• . ,. • • . , • . . . , . • . • .• , . . . . . . •• . . . .• • • - I-'. • • . . ... . . .• . ' . • ..•,. . • . s -. . . . .. . • ...• . 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CI GARY FMAGUETTE ,- ..'.:::•••, .., .-• . •-•-,„. :::.• a, .. . ,...... ......• . ..... . - 67 PAAPLE AVE .- •,• _.-. ., •_ . . , e • ' .-. • -let'' y•-is- iffANISSAWki---02601-4. 9.„!1‘41-:_.,,, , .. •:,.z..„t•::, :-_----,-;-,,.• ..- ... ...• • • -1 ...••• . ... . ...,:r.„, ,,,,..,,i,:. 4sti• ,•. . . . • . .t.,..,,, -7.-;ffe 3... .... .:... ..,' ... . , • • ' ....,..:- . . . • . 10191 . :. .!:.. ... . .--06/0112022 .. . . . -- 01453 . . . • "" E t3 •,,,,:,...•...tV::!'ii:.2.1,,•:-. -. :: • ."- . ..:• ..:.:. -..• . • '' . t !ABER" • :'0... •':'•':'',„,.-.-.."N. .DAT.-F... .. , . .BMOC. ,..._. :,,2..... .-...... ,•;,,,,:;.;-•,.„) . • • , . `‘, 'fri . • • a' • . •:t{ • . . 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Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): -„ t y" ( ,cv {—(m t c ff._ s\l j`A I0/1 C( ' Address: (a-7 v� c, c t A v e C,v► -n i S V t✓. QQ 0 %?S- ,j 5 E-- City/State/Zip: ! Phone#: '- ' - Are you an employer?Check the appropriate box: •Tie of project(required): • • `l. • 1 am a employer with 4. I am a general contractor and I 6. New construction do .employees(full and/or part-time).* have hired the sub-contractors • - ..--ship 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling h ip and have no employees These sub-contractors have 8. Demolition • • Workin for me in anycapacity. employees and have workers' g P h' 9. Building addition INo workers'comp. insurance comp. insurance.$ iequired_] _ 5. We are a corporation and its 10. Electrical repairs or additions ` ' 3. • •I am.a homeowner doing all work officers have exercised their 1 i. Plumbing repairs or additions.' • • Myself. [No workers'comp. right of exemption per MGL 12. Roof repairs • ' insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13. Other comp. insurance required.] • . , *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t llomebwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. . tContractors 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: I . Policy#or Self-ins.Lic.#: Expiration late: - Job Site Address: City/State/ •p: • Attach a copy of the workers' compensation policy declaration page(showing the poll number and expiration date). ' .' _ Failure`to secure coverage as required under Section 25A of MGL c. 152 can lead to the im osition of criminal penalties of a. s4 fine tip to$1:500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine .A ()Cup to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investi^ations of the DIA for insurance coverage verification. ..I , . l do h ,reb ycertify unde the pains and penalties of perjury that the information provided bo'e is true and correct • . , • • Signalere: 7.---.\- Date:/G y ,4 . • • Phone#: 5 U f1— 77$ — `a 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): . . I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector , . . 6.Other • Contact Person: Phone#: