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HomeMy WebLinkAboutBLDP-21-001559 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 9/25/20 PERMIT# BLDP-21-001559 JOBSITE ADDRESS 9 LOCH RANNOCH WAY OWNER'S NAME GILLIGAN DIANNE 0 P OWNER ADDRESS 9 LOCH RANNOCH WAY YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES El NO El FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION _ WATER HEATER _ WATER PIPING 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 El NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF 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. 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 Plumbirg Code and Chapter 142 of the General Laws. PLUMBER'S NAME Troy Gilbert LICENSE 16573 SIGNATURE MP El JP El CORPORATION ❑# I PARTNERSHIP ❑# LLC ❑# COMPANY NAME [(COASTAL MECHANICAL ADDRESS 21 L Fruean Ave CITY WAREHAM STATE MA 7 ZIP 025711324 1 TEL FAX CELL —I EMAIL lisa@coastalphc.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK MN- CITY Yarmouth Port MA DATE 09/16/2020 PERMIT# 2I-(b 1557 — JOBSITE ADDRESS 9 Loch Rannoch Way OWNER'S NAME Leda Knight POWNER ADDRESS Same TEL FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL I I EDUCATIONAL Li RESIDENTIAL Li PRINT CLEARLY NEW:____I RENOVATION:Li REPLACEMENT:71 PLANS SUBMITTED: YES Li NOn FIXTURES Z FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB [ HE nr_ 1 -1r. — I r I� -1 --_y1 CROSS CONNECTION DEVICE [ 1 J___-_ . 7r DEDICATED SPECIAL WASTE SYSTEM r— I. -I DEDICATED GAS/OIUSAND SYSTEM —II-----it [ r- _-;, DEDICATED GREASE SYSTEM -- DEDICATED GRAY WATER SYSTEM y. J _11-1'' J 1 DEDICATED WATER RECYCLE SYSTEM I in— IfJ DISHWASHER 1 , 11� l- DRINKING FOUNTAIN ]L J FOOD DISPOSER 1 FLOOR/AREA DRAIN '.i- ----'— INTERCEPTOR(INTERIOR) KITCHEN SINK 7 1 IL ._j, b si LAVATORY —jr --1_ ROOF DRAIN fir— ' i v _L SHOWER STALL ' Tir _I_SERVICE/MOP SINK ,( [ TOILET ii „ URINAL _I _ li d_ WASHING MACHINE CONNECTION 1' �� 11` WATER HEATER ALL TYPES .1_ _.=_IL�., _ — WATER PIPING — 1 OTHER _IL_ r__ j 'y _,_L.—!L_.. >i .. I,,. ------ -- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES i NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IJ OTHER TYPE OF INDEMNITY Li BOND I j 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 I I 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 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 chance with all Pertin n provision the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.PLUMBER'S NAME[Troy Gilbert /��I LICENSE# 13573 IGNATURE MP2j JP El CORPORATIONQ#L IPARTNERSHIPI,, I# 1 nor, # 4350 COMPANY NAME Coastal Mechanical (ADDRESS 21L Fruean Ave CITY South Yarmouth STATE MA I ZIP r02664 TEL r 508-737-8747 G` FAX i CELL 508-850-6955 EMAIL lisa@coastalpch.com ��� Cu • The Commonwealth of Massachusetts t ='f I Department of Industrial Accidents • 1 1 I Congress Street,Suite 100 Boston,MA 02114-2017 G 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):Coastal Mechanical Address: 21 L Fruean Ave City/State/Zip:South Yarmouth, MA 02664 Phone#: 508-737-8747 Are you an employer?Check the appropriate box: Type I project(required): 1.6/1 am a employer with employees(full and/or part-time).* 7. f,New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. [ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 l am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.0 1 am n homeowner and will be hiring contractors to conduct all work on my property, I will ❑ ensure that all contractors either have workers'compensation insurance or are sole 11. lectrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.0 lam a general contractor and I have hited the sub-contractors listed on the attached sheet, 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.' 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other HVAC 152,41(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 trust submit a new affidavit indicating such. '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 ant an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site information. Insurance Company Name: AIM Mutual Policy II or Self-ins.Lic.#: WMZ80080074082020A Expiration Date: 01/04/2021 Job Site Address: : 9 Loch Rannoch Way eity/S(ate/zip: Yarmouth Port, MA 02675 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 pedury that the information provided above is true and correct. Signature: 949,4 Date: 09/16/2020 Phone#: 508-737-8747 _ 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 1 Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#i r • • • '',COMMONWEALTH OF : ti,.r; t 0 1 1 ION O M, tHl $�i <:< "O SI t.AL �.:. PLUMBEk klicASFI,FT �" ;n ISScJE. THE FOLLOWING E1 E ISE - . Rr 'JGILBERT ,3 ., `�,y , `;,,•CO STA��?� ThflBING AND HEAT' G t ' 1 39 STAtION S�fReET. ~< .; �a ', ti, WYA �� 4 . z IiFvHAM,MA t)25y L '' i tt}'' ..• £ � s. 4350 'z '.^` .' p3101/2022. H� „ 856115 j` LICENSE NUMBER _ EXPIRATION DATE SERIAL NUMBER ,Oil''',:‘ OMMO W LT o `t N l t DIVISION OF PRO//F�EppS��SIONAL LICENSURE w < PLUMBERSANrGASFITTERS I ',� � t ISEf4OLLOWNGk'CE4E 1� %. URNEY ,,aa ;.3 it • s yJ GILBERT z '"'«,. / 7, , '% ,� YU. tATtO F, 's1. . WARERAA, fA'02571..1 �`az� j;h a'' 19-, ;/.t 25383+" f '� 0&01120 � .R Y tiw� l' 831568 s i LIC NSE NUMBER EXPIRATION DATE SERIAL NUMBER •• CONTROL # J01462784 CONTROL J01438281 IMPORTANT IMPORTANT ! If.your license is lost,damaged or destroyed;is Inaccurate;or ed or destroyed;is Inaccurate;or needs to be corrected,visit our web site at mass.gov/dpl for if your license is cost,damag needs to be corrected,visit our web siteoft o ar Re ewalpl for 1 instructions to ensure the proper mailing of your Renewal ro er mailing Y 4 instructions to ensure the p p Application and any other correspondence. Application and any other correspohdence• This license is subject to Massachusetts General Laws and and cannot be lent or This license is subject to Massachusetts General Laws an • • regulations.Your license is a privilege,and cannot be lent or ulations.Your license Is a pr liege, enalt of law.Keep this assigned to any person or entity under penalty of law.Keep this a 9 latioigned to any person or entityunder p Y license on your person or posted as required by law and/or license on your person or posted as required by law and/or regulations. regulations. Client#:764315 2COASTALPLI ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS0 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT The Hilb Group of N.E.dba NAME: PHONE 508 775-1620 Dowling&O'Neil Insurance Agy (A/C, 'mot)' ram,No 5087781218 P.O.Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIc INSURED INSURER A:Evanston Insurance Company 35378 INSURER B:A.I.M.Mutual Insurance Company 33758 Coastal Plumbing&Heating LLC Dba Coastal Mechanical INSURER C:Safety Insurance Company 39454 299 Whites Path INSURER D: South Yarmouth,MA 02664 INSURERS: 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 ADDL SUER LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMMIUDDNY YYY) (MtMMIUDDY/YEXP YYY^Y) LIMITS A X COMMERCIAL GENERAL LIABILITY MKLVIPBC000737 01/04/2020 01/04/2021 EACH OCCURRENCE p �q�EMISE $1,000,000 PR CLAIMS-MADE X OCCUR ES(Es oNc uurrence) $100,000 X Bl/PD Ded:5,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 GENt AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 POLICY I X JECOT I I LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: C AUTOMOBILE LIABILITY 5906835 01/04/2020 01/04/2021 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $1,000,000 SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY x AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED X AUTOS ONLY X AUTOS ONLY PROPERTY DAMAGE (Per accident) $ $ A UMBRELLA LIAR OCCUR MKLV1 EUL102215 01/04/2020 01/04/2021 EACH OCCURRENCE $1,000,000 X EXCESS LIAR X CLAIMS-MADE AGGREGATE $1,000,000 DED I I RE,ENTION$ $B WORKERS COMPENSATION WMZ80080074082020A 01/04/2020 01/04/2021 X ITAUTEI PP- AND EMPLOYERS'LIABILTY OFFICERO/MEMBEROCCCLU OCCLUDED?PROPRIETOR/PARTNER/EXECUTIVE N/A (Mandatory in NH) E.L.EACH ACCIDENT $1,000,000 If yes,describe under E.L DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISFASE-POLICYLIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I 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 the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Hall THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 134 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ' ...,. C. ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #5251644/M251588 LS1