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HomeMy WebLinkAboutBLDG-21-004891 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK (k!=flyil`fl CITY YARMOUTH MA DATE March 01,2021 PERMIT# BLDG-21-004891 6 JOBSITE ADDRESS 18 ROADS END OWNER'S NAME GABRIELS JEFFREY K G OWNER ADDRESS GABRIELS JO ANNE TAYLOR 299 ELLIOT RD EAST GREENBUSH NY 12061 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 Keith Farnham LICENSE# 11601 SIGNATURE MP© MGF 0 JP❑ JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: SOUTH SHORE HEATING&COOLING ADDRESS. 57 White's Path, CITY South Yarmouth STATE MA ZIP 02664 TEL FAX I I CELL I I EMAIL info(a,southshoreheatingcoolinq.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 4:'J` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t.f=? CITY: ti,,earx otet t MA. DATE: 2.-2/42 Z4:::>21 PERMIT# L b&' ce-119qi JOBSITE ADDRESS: 1I OWNERS NNAAME/.� ,f l S GOWNER ADDRESS: �i 7E'L: 46 " f (6/-FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er--- PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:2--- PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-1 FLOOR-4 Bsmt 1 2 3 4 5 1 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 w LABORATORY COCK MAKEUP AIR UNIT l OVEN POOL HEATER ROOM/SPACE HEATER -.} ROOF TOP UNIT fi TEST ` UNIT HEATER U UNVENTED ROOM HEATER , WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES E0 ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY Er 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 Massachu tts General La ,a 41040 my signature on this permit application waives this requirement. 0e �� h� Q�l/l"/ CHECK ONE ONLY: OWNER ❑ AGENT [� SIGN TURE OF CNVNE R AC ENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are and• a t of my Knowledge and that all plumbing work and installations performed under the permit issued for this appllcatlo In • griewith Pertinent provision of the Massachusetts State PI biingg C de and Chapter 142 of the General Laws. ,� f • ✓�' / P UMBERIGASFITTER NAME: / /T IG Li ENSE# /66/ SIGNATURE C PANY V/ D :�� i �� 5 4�``L CITY: _At "- i vt STATE ZIP: 6 7 FAX: V:S-.390"": -nO/ CELL: EMAIL: /47 I "% .(, MASTER2JOURNEYMAN❑ LP INSTALLER❑ CORPORATION Ell PARTNERSHIP❑)# _ LLC❑# EInf}/L. A1)DA2c.Ss : ..._ The Common wealth of Massachusetts r ,fi1 P Department of Industrial Accidents 9 eNfl= 1 1 Congress Street,Suite 100 "• ' 02114-2017 * _a_�= Boston, MA ' �4 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legi lv a v ' Name (Business/Organization/Individual): it JIrt,(/. 7,,y . C R`�j,�_ e, , j . J;,,, Address: � L Y �t` S �r'�J �V� City/State/Zip: G lrlicu9c-k., A Pho # SO� �p ` Are you an employer?Check the a priate box: Type of project(required): 1.21 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. t 9. ❑Demolition ❑ ys (No workers'comp,insurance required.] 10 ❑Building addition 4.❑I am a 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.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.1:I am a general contractor and I have hired the sub-contractors listed on the attached sheet I3.❑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 152,§1(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 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. y�� Insurance Company Name: A 1LCare.A3 p( -6 .1.IF�O �p e e"`,1 Policy#or Self-ins.Lic.#: 1.t)CC,�5 (7''5, 2020 4 Expiration Date: 7/t 2c7 / Job Site Address: t 5 i ,,. )dir141CLACPL City/State/Zip: �GTi • cZ(2 5 Attach a copy of the workers' compensation policyaration 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 an aloes of perjury that the information provided above is true and correct, Si nature: ( Date: 2.— a.40 ?-01 Phone#: ©t 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): r 1. Board of'Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �„.....4,41 MACFENE-01 DDELEO 4 2 RE3- CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDrYYY) �� 6/29/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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 rights to the certificate holder in lieu of such endorsements . ' CONTACT Denise DeLeo PRODUCER NAME: People's United Insurance Agency, Inc. PHONEExt): (508) 692-6903 843 FAX No1:(855) 334-9011 __ 10 Commerce Way #3 E-MAIL Raynham, MA 02767 . ADDRESS: Denise.Deleo@peoples.cam INSURER(S)AFFORDING COVERAGE _... .___-1 NAIL#---._,__ INSURER A: Houston S.peciaity_.Insu.rance Company 112936 ____, 1 INSURED _-INSURER B :.Irnperlum Insurance Company _ _ ----........'35408 MacFarlane Energy, Inc, INSURER C: North River Insurance Company _ 21105 dlb/a South Shore Heating & Cooling 95 Bridge Street INSURERp;Associated Employers Insurance Company. 11104___ Dedham, MA 02026 ° INSURER E: --._- -------------_ ; __--- -_ 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 I 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' ADOLSUBR: POLICY EFF POLICY EXP ' LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER fh1MIOWYYYY).: (MMIDDIYYYY) . A 1 X TCOMMERCIAL GENERAL LIABILITY I I EACH OCCURRENCE _ $ 1'000,000 I DAMAGE TO RENTED '{00 000 CLAIMS MADE X OCCUR :ECAPI-HS-GL•000130.00 7/1/2020 7/1(2021 -P-REM ES(Ea_o�ru-r�ence). 1�.,.._-_.-.-._ .__ ' MED EXP(Any one person) I 1,000,000 I PERSONAL &ADV INJURY _'_$_ ... AGGREGATE AL GENER r , GENT.AGGREGATE LIMIT APPLIES PER: • ` $ 2,000,000 -- - - --- -- -•••-- PRO 2,000,000 POLICY • JECT LOC , - - • ( i OTHER: __-_ i $ COMBINED SINGLE LIMIT I 1000000 s AUTOMOBILE LIABILITY Ea a $ ' '._ ' X ANY AUTO ;ECAPI-IIC-MACH-000130-00 7/1/2020 7/112021 BODILY INJURY(Perpersoi) $ __ i OWNED • ' SCHEDULED ; AUTOS ONLY i -j AUTOS I. BODILY INJURY(Per accident) $ i --- X HIRED X NON-OWNED • PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) X MCS90 Indl X MM9955 Pollution , $ C ' UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 10,000,000 5811113772 7/1/2020 71112021 10 000,000 X ; EXCESS LIAB CLAIMS-MADE AGGREGATE !S -. _-_-, I DED i I RETENTION$ V i I $ D I WORKERS COMPENSATION I I - I X STATUTE ER I ER OTTH- AND EMPLOYERS'LIABILITY Y 1 N ANY PROPRIETOR/PARTNER/EXECUTIVE " WCC50050175552020A i 7/1/2020 I 7/1/2021 ; E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Ni1 N I A! I 1,000,OQ0 (Mandatory In NH) I-El.DISEASE EA EMPLOYEE $If yes, describe under ' '1 000 000 DESCRIPTION OF OPERATIONS below , i E.L.DISEASE-POLICY LIMIT $ i ; • • DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Operations of the Insured CERTIFICATE HOLDER T CANCELLATION _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For information purposes ACCORDANCE WITH THE POLICY PROVISIONS. • AUTHORIZED REPRESENTATIVE Paige-rod Vowed Towataftee 749efteet, Tpte., ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD