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Home My WebLink AboutBLDG-21-001725 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Cs CITY YARMOUTH MA DATE October 05,2020 PERMIT# BLDG-21-001725 JOBSITE ADDRESS 14 LILY POND DR OWNER'S NAME CUGINI DAVID J TRS G OWNER ADDRESS CUGINI RITA D TRS 14 LILY POND DR SOUTH YARMOUTH MA 02664 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 1 FRYOLATOR FURNACE GENERATOR GRILLE 1 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 Andrew Leighton LICENSE# 16130 SIGNATURE MP Q MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑ # PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Andrew R Leighton ADDRESS. 20 Brewster Rd, CITY W Yarmouth STATE MA ZIP 026735706 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 ❑ ❑ "// , FEE:$ PERMIT# PLAN REVIEW NOTES CrO • 6V MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY yP 0 i-'o v L K MA DATE ?../705 PERMIT# UtJ.N��I r wl `S JOBSITE ADDRESS /� �c/1� i9� '°' OWNER'S NAME -cue kIIeA/ �'G';U GOWNER ADDRESS /' r r TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL V/ PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS—. BSM 1 2 I 3 4 5 6 7 8 9 10 11 j 12 13 14 BOILER BOOSTER • I CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I ! I , 1 DRYER FIREPLACE FRYOLATOR _ .. . ' I FURNACE ' I GENERATOR GRILLE }C . INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT I OVEN POOL HEATER ROOM/SPACE HEATER I I ROOF TOP UNIT TEST UNIT HEATER 1 I UNVENTED ROOM HEATER ,.. . WATER HEATER OTHER l f I ' i k 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 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY , 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 0 Y: 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 a and ar e t he b t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c plian vynt II P rti rovi ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • / I PLUMBER-GASFITTER NAME ANDREW LEIGHTON LICENSE# 16130-M f/ SIGNATURE MP MGF JP JGF LPG! CORPORATION 3734C PARTNERSHIP LLC # COMPANY NAME: HALL OIL COMPANY INC. ADDRESS 435 RT 134 CITY SOUTH DENNIS STATE MA ZIP 02660 JIAIL TEL 508 398 831 FAX 508-394-3068 CELL Eh halloilcompany@gmail.com The Commonwealth of Massachusetts Per l r-e cQ L La . Department of Industrial Accidents tt _ Tii�, l Office of Investigations ,Vi4 N CK C'vZ4 � ��4 600 Washington Street Boston, MA 02111 N'T 4. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): AVL h '(6 CC . 27/i?G' Address: ' -3 5 f;/e /3 / City/State/Zip: S o . Din t s H/9 Phone#: cod' - 3 2 "3 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with /8 4. I am a general contractor and I have hired the sub-contractors employees(full and/or part-time).* 6. New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' y Building addition [No workers' comp. insurance comp. insurance.* required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their dr Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] } 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. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Ain 772,9 Z)i c J ' f-T/t/SO// AN CE c'X'UC��, ZWC Policy#or Self-ins.Lie.#: 0 o?/4 0 '7"/OC /9,V/ 0 Expiration Date: //�oZ/ Job Site Address: r „6 f�l' /-11-' s. A OR• City/State/Zip: � R p�6.6y 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$250.00 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 certify u der the pains �and penalties of perjury that the information provided above is true and correct. Signature:,/ �- s' Y—os� a / ` _ Date: //),, �G3 Phone#: 3 7 0 3 rr' Y 3 ?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): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: