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Home My WebLink AboutBLDG-21-001365 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK = )! CITY YARMOUTH MA DATE September 16,202 PERMIT# BLDG-21-001365 so JOBSITE ADDRESS 49 SHALLOW BROOK RD OWNER'S NAME ORENSTEIN ROBERT I G OWNER ADDRESS 20 FAIRLAND CIR RD#2 SOUTH DENNIS MA 02660-1907 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 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 Troy Gilbert LICENSE# 13573 SIGNATURE MP 0 MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: COASTAL MECHANICAL ADDRESS. 21 L Fruean Ave, CITY WAREHAM STATE MA ZIP 025711324 TEL FAX CELL EMAIL lisa(a�coastalphc.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES ... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r� CITY South Yarmouth MA DATE 09/14/2020 PERMIT # c3L6&-2I{VDI 3us- Rax.i___„,„, JOBSITE ADDRESS 49 Shallow Brook Road OWNER'S NAME t Robert Orenstein GOWNER ADDRESS 20 Fairland Circle Road #2, South Dennis. MA 02660 TEL' 1FAXt TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL r RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: i PLANS SUBMITTED: YES NOD APPLIANCES Z FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1m,� W BOOSTERIl- CONVERSION BURNER ____ COOK STOVE DIRECT VENT HEATER l DRYER FIREPLACE FRYOLATOR .... . ,.. _ . .....,.. I ---11------11--- _ FURNACE --1._.. __ - GENERATOR ._ � GRILLE �' INFRARED HEATERit_ j ,- L it- LABORATORY COCKS F___ MAKEUP AIR UNIT � 4 OVEN .... Fes. POOL HEATER ROOM / SPACE HEATER _ _ ----------- ROOF TOP UNIT _�. .Ii.ro..... _ TEST UNIT HEATER UNVENTED ROOM HEATER i WATER HEATER _ OTHER r--- .a.. ...ariiiiij INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES : NO 0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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 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. 1351, ,.zeoAi- PLUMBER-GASFITTER NAME Troy Gilbert LICENSE # SIGNATURE MP MGF JP JGF I ,r LPG' CORPORATION ®#` PARTNERSHIP N#1__ JLLC #14350 COMPANY NAME: Coastal Mechanical ADDRESS 21 L Fruean Ave ...........____............___d CITY South Yarmouth STATE MA d ZIP 02664 TEL 508 737 8747 4 FAX CELL 508-850-6955 EMAIL lisa@coastalphc.com C( d.04 1 C- OMMONWEALTH OF M' . I.. =F tl' ::'i >'., DIVISION OF PROFESSIONAL LICENSURE �.• , y� PLUMBEI4SAND GASF1'�TE �'($': le t '' 1SSVF. Tt E FOLLOWING ICE�NSE `,:•• -TEREq.P•Lpf t tkib c 13-1,;°s,,. �., LTR 'J GILBERT z.•t'=,° `o ley ,� �`` r" ' ,C ly�4 � coasrq i 7 4 k t' u�• L ,�lfi�tFNG AND HEATI_ G r 39 STAT.dN-S3�tRT. "',:.. °, ', .� • ,F a WAREHAM,MA D26�'1� s. 'it 1,',i�: s�"• ,ss s v °` 435o r`ii. ',,�45/t)1f20,Z2 856115 LICENSE NUMBER EXPIRATION`DATE SERIAL NUMBER (:) OMMO W LTH OF mi "7- DIVISION OF PROFESSIONAL LICENSURE s H BQARD Q1' v, � PLUMBEt +4N1�`'GASFITFTf ' I `' ISSUES,,,,T.iE FOLLOWING LfttiVrSE w. 3 I ``; �.quRFIEYMA, ektih,jBER: ; ••:;� J GILBERT % `t1. u r: 1,�OW'if • _ ,s ��,, a.� I • VVAREil*,,P1A (4571,1t21.,w1 .....:,„.:,,.... , '0' .••/'. : ` 25383 s anal/2n2 83d68 dq> LICENSE NUMBER EXPIRATIONDATE SERIAL NUMBER • 9 —r--___te , CONTROL# J01462784 CONTROL# ,J01438281 IMPORTANT ! IMPORTANT If your license is lost,damaged or destroyed;is Inaccurate;or It your license is lost,damaged or destroyed;is Inaccurate;or needs to be corrected,visit our web site at mass.gov/dpl for needs to be corrected,visit our web site ft oua Renewalpl for instructions to ensure the proper mailing of your Renewal instructions to ensure the proper mailing y Application and any other correspondence. Application and any other correspohdence. it This license is subject to Massachusetts General Laws and and cannot Lawsbe lent or This license is subject to Massachusetts General and assigned to any rperson eor entity is a ti sunder penalty ofe,and t law.be IKeep ent rthis regulations.Your lie son oense r entity sunder p of law.Keep this penalty rj license on your person or posted as required by law and/or assigned ss licegse on your person or posted as required by law and/or w regulations. regulations. Client#: 764315 2COASTALPLI ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON HOLDER. THIS S0 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: PHO NE 508 775-1620 5087781218 o,Est):Dowling&O'Neil Insurance Agy E-MAIL (aC,No): P.O.Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIL INSURER A:Evanston Insurance Company 35378 INSURED INSURER B:A I.M.Mutual Insurance Company Coastal Plumbing&Heating LLC 33758 Dba Coastal Mechanical INSURER c:Safety Insurance Company 39454 299 Whites Path INSURER D South Yarmouth,MA 02664 INSURER E COVERAGES INSURER F: 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 SUBR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY» LIMITS A X COMMERCIAL GENERAL LIABILITY (MMlDD/YYYY) (MM/DD MKLVIPBC000737 01/04/2020 01/04/2021 EACH OCCURRENCE $1,000,000 I CLAIMS-MADE I Xi OCCUR DAMAGETO RENTED X BI/PD Ded:5,000 PRE I S Ea occurrence) $100,000 MED EXP(Any one person) $ GENIAGGREGATE LIMIT APPLIES PER; PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 PRO- POLICY P X JECT LOC POLICY PRODUCTS-COMP/OP AGG $2,000,000 C AUTOMOBILE LIABILITY $ ANY AUTO 5906835 01/04/2020 01/04/2021 (Eaa deDSINGLELIMIT $1,000,000 OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY X AUTOS HIRED NON-OWNED BODILY INJURY(Per accident) $ X AUTOS ONLY X AUTOS ONLY PROPERLY DAMAGE (Peraccldent) $ A UMBRELLA LIAR $ _ OCCUR MKLV1EUL102215 01/04/2020 01/04/2021 EACH OCCURRENCE X EXCESS LIAR X CLAIMS-MADE $1,000,000 AGGREGATE $1,000,000 DED I I RETENTION$ B WORKEANDEMPL YERS'LIAILI WMZ80080074082020A 01/04/2020 01/04/2021 X IPER I I $ AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N STATUTE ER OFFICER/MEMBER EXCLUDED? N N/A E.L.EACH ACCIDENT $I,000,000 (Mandatory In NH) Eyes,describe under E.L DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/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 POUCIES 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 ©1988-2015 ACORD CORPORATION.AU rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #52516441M251588 LS1 • • . The Commonwealth of Massachusetts )•=-'�el Department of f Industrial Accidents • .9_, �§1_" 1 Congress Street,Suite 100 �-i"t_ e SIN Boston,MA 02114-2017 »,,,-, www.mass.gov/din `r Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Legibly Name(easiness/orgenizalion/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 o project(required): VI I. mnaemployerwith employees(full and/or 7. New construction 2.0Iama sole proprietor or partnership and have en employees working for to 8. [Remodeling any capacity.[No workers'comp.insurance required.] ID I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 9. ID Demolition 10❑Building addition 4.0 I am Ithomeowner and will be hiring contractors to conduct all work on my property,t will ensure act all contractors either have workers'compensation insurance or are sole I1, lectrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions I.Q l era a general contactor and I have hired the sub-contractors listed on the attached sheet, 13.0 Roof repairs These sub-contactors have employees and have workers'comp.insurance.) 6,0We are a corporation and its officers have exercised their right of exemption per WI-c. 14.[�Ofbet HVAC 152,§I(4),and we have no employees.(No workers'comp.insurance required.' *Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit Indicating they are doing as work and then hire outside aontractots must submit a now affidavit indicating such. IContmclors drat check this hoe must attached an additional skeet showing the name of the subcontractors and state whether or not those entities have employees,If the sub-contractors have employees,they must provide their workers'corny.policy number. l am 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 ttl or Self-ins.Lie.it: WMZ80080074082020A Expiration Date: 01/04/2021 Job Site Address: , 49 Shallow Brook Road city/state/zip: South Yarmouth,MA 02664 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL a.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. 1 do hereby certify under the pains •awl penalties ofperjary that the information provided above is true and correct. Signature: �• Ix-¢4--/trin,lasz, Dena: 09/14/2020 • Phone B: 508-737-8747 • Q/J?cial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License d Issuing Authority(circle one): 1 I.Board of Health 2,Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other i Contact Person: Phone it: i i i