The URL can be used to link to this page

Home My WebLink AboutBLDG-21-003832 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE January 11,2021 PERMIT# BLDG 21-003832 "' JOBSITE ADDRESS 446 ROUTE 6A OWNER'S NAME COX JOSEF PAUL G OWNER ADDRESS COX D MELISSA 446 ROUTE 6A YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR , FURNACE GENERATOR GRILLE • INFRARED HEATER LABORATORY COCKS , MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER , ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 r OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY El 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. 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 Gregory Selfe LICENSE# 26714 SIGNATURE MP❑ MGF ❑ JP El JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: GREGORY A SELFE ADDRESS. 41 SPRINGER LN, CITY WEST YARMOUTH STATE MA ZIP 026734930 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT D ❑ e_ A 1/z/1J FEE:$ PERMIT# ifJ PLAN REVIEW NOTES M-1ASSAUHUSE 1 I S UNII-UKM ArrLIUHI IUIV rum H rtmivii l Iv rcr rvrtwl uiw rI 11 111117 vvVRrX =' '�' yA, r., I' 1 PERMIT # �'3L. ( - = � CITY MA DATE JOBSITE ADDRESS y q 6 1Zr 6 A OWNER'S NAME cox GOWNER ADDRESS 9 Y 6 It'r 64 TEL(5-°2) C$'- 4 ?6 'AX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL IA RESIDENTIAL PRINT CLEARLY NEW: n RENOVATION: n REPLACEMENT: *j PLANS SUBMITTED: YES n NO n APPLIANCES 7. 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 GENERATOR GRILLE INFRARED HEATER ----- - LABORATORY COCKS MAKEUP AIR UNIT r OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT ' R CE, It 'CZ /- 4 TEST f .. p" ,.� r UNIT HEATER ''' 221 UNVENTED ROOM HEATER 1# WATER HEATER ,,. LZl`iel o6w,gRr OTHER 1 MEIVr INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1. NO n , '_a) I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - .k •-'/\)(/ LIABILITY INSURANCE POLICY 'S3 OTHER TYPE INDEMNITY BOND n x,, 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 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. 6‘..---- PLUMBER-GASFITTER NAME 6-Ca ogy ceire LICENSE #,:g Ity GN UR MP MGF JP41 JGF LPGI ❑ CORPORATION — # PARTNERSHIP n # LLC n # COMPANY NAME&Ce O 7sett[- 1A 4ccle ‘t` `e- ADDRESS £{( S9Kfrat4- 4-44 (1& CITY (A-) ' YKrn' STATE r4 ZIP 04.6 /3 TEL (51.°1?)..-IN - it( 3Y FAX CELL( ° ) *Y _ i431 EMAIL SSet Cr-i fir ty ,,o.t,o-tv. 6b -CI D Deprutment of Xrrcizcstri1tTACcidenfs • 4 _ 1 Congress Street,Sate 100 rad'_' ' Boston,MA 02114 2 01 7 • 11i vw mass:gov/[Iles Workers:Compensation Insurance Affidavit:Builders/Contracto rsiElectricians/Plumbers. TO BE TILED WYrn LHL PERIsanING AU'LHOrtITY. Applicant Information Please Print Legibly • Name(Busincss/Organ:nation/Individual): 6-rozloi.i.y S ti- •Q "6 h c`a`' _ Address: - • • yNt fi 044i ) -1-1': -ill y , City/State/Zip: to- phone#: . Arc you an employer?Check the Appropriate bo Type of project(required): 1,0 I am a employer with employees(full andlorpart-time).* • 7_ El Nay construction - 2.:K .am a sole proprietor or partnership and have no employees worlong forme in $_ ,Remodeling ' KKTTaany capacity,[No workers'comp.insurance required.] 9_ ❑Demolition 3-01 arri a.homeowner doing all work myself No workers'comp:insurancere.quirrai]t 1 D O Building addition . 4,01 am a bomcowncr and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation ir+sumnce or are sole 11.0 EIectrical repairs or additions • proprietors'kit no employees 12-[(Plumbing repairs or additions 5.0I am a grncral confraciorand I have hired the sub-contractors listed onthe attached sheet 13 nRDofrLpaiiS These sub-ccontractors have employers and have workers'comp.insurance?" 14-DOther . 6 0 We are a corporation and its officers have exercised thcirriglrt of exemption perMGL c- 15Z§1(4),and We have no employed No worlirs'comp.insurance required.] • ' *Any applicant thatches s box#1 must also fill out the section below showingthcirworkcrs'compensation policy information. t gomcuwnea who submit this a>6dayitindicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that cheek this boa must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I turn aix employertlurt is providirrgtPorkers-'compensation insrrranr-for my enrployeer. Below Is-theepolicy curdjob site irtforIrwf on. - Insurance Company Name: ' • Policy#or Self-ins.Lie_# Expiration Date: Job Site Address: • - City/State/Zip: • Attach a copy of the workers'compensation policy declaration page(showing the policy mu bet-atid expiration date). Failure to secure coverage as required underMGL c_I52,§2SA is a criminal violation punishable by afne up to T1,500.00 and/or one-year imprisonment,a$well as civil penalties in the form of a STOP WORK ORDER_and a Eno 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 DI A.for insmancc coverage verification. . I do hereby cerit&under the pears and erurltirs of,perjury thntihe information pruPidcd above is true and correct, Siznat[rre: Date: i -4( - 4t • - • Phone#: .1!/1_ 1N1 - or►I/ • - Of/Tr-Far use only_ Do not write in this urea,to be completed'by ci Dr town affidaL • city or Town: Permit/Liccnse#. , Issuing Authority(circle one): • • 1.Board of Health 2.BnidingDepartroent3-Crt'ITownClerk 4.ElectricalInspector S.Plumbing Inspector , 6.Other Contact Person: Phone if: g