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HomeMy WebLinkAboutBLDG-21-004639 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tI,M," CITY YARMOUTH MA DATE February 16,2021 PERMIT# BLDG-21-004639 f- "0 JOBSITE ADDRESS 27 SPRUCE ST OWNER'S NAME WELCOME TIMOTHY P G OWNER ADDRESS CAMPBELL WELCOME MARY E 51 POTTER HILL RD GRAFTON MA 01519 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL EI PRINT CLEARLY NEW: ❑ RENOVATION:D REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 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 michael pierce LICENSE# 34718 SIGNATURE MP❑ MGF 0 JP❑ JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 4 kaycees way CITY west yarmouth STATE MA ZIP 02673 TEL FAX CELL I EMAIL mapierce774qmail.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 0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _die_ =�1- CITY SCiC.i V Ll \ A(610,- - , MA DATE 3,1 (')/a.- I PERMIT# a1--DG -It— oOLjM JOBSITE ADDRESS a 7 52roce % r OWNER'S NAME f\ t 1'11 GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT ❑ ❑ RESIDENTIAL©� CLEARLY NEW: ❑ RENOVATION:"EPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO 5. APPLIANCES 1 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 I 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT L r r OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER — WATER HEATER OTHER - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES 'NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY El 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 CHECK ONE ONLY: OWNER El 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 w 1(Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -(- / _ PLUMBER-GASFITTER NAME LICENSE# . . SIG RE MP El MGF El JP Er JGF❑ LPG! ❑ CORPORATION ❑# PARTNERSHIP El# LLC ❑# COMPANY NAME Pie. CL PI(...•rY}b 1Y1 1 ke iG%4(:ii&t.t-j ADDRESS q /4-6 yc f, 1..,..(, CITY t'k'i"= }- "I ( mc%,_•�h STATE s Li4 ZIP (`,),(-. _7 ,3 TEL 7 7(i 7,) 3.1-j- I FAX _ CELL EMAIL r itl -~Ce_P/C/mb/k7 Sc rv'ce_ 6M41..C sin ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY) 02/09/2021 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 endorsement(s). PRODUCER CONTACT C NAME: hris Fournier Berlin Insurance Grou PHONE (508) 459-1226 ! FAX p (A/C. O. Ext): (A/C, No): 61B MILTON ST E-MAIL i li b Chris ernnsurance rou ADDRESS: @ g pcom INSURER(S)AFFORDING COVERAGE NAIC# WORCESTER MA 01606-2819 INSURER A : UNION MUTUAL FIRE INSURANCE CO. 25860 INSURED INSURER B : MARKEL INS CO 38970F Michael Pierce DBA Pierce Plumbing & Renovations INSURER C : 4 KAYCEES WAY INSURER D : INSURER E : WEST YARMOUTH MA 02673-2612 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 TYPE OF INSURANCE ADDLISUBR' POLICY EFF T POLICY EXP LIMITS LTR 1NSD 1 WVD POLICY NUMBER JMMIDD/YYYY) (MM/DDIYYYY) X COMMERCIAL GENERAL LIABILITY j I EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ MED EXP (Any one person) $ 5,000 A BOP0186527 11/02/2020 11/02/2021 PERSONAL&ADV INJURY $ 1 ,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY jE LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: _ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED N ON-OWNED PROPERTY DAMAGE $ AUTOS ONLY , AUTOS ONLY (Per accident) I $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER I I OTH- AND EMPLOYERS' LIABILITY STATUTE ER Y!N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? N N/A MWC0176264-01 11/02/2020 11/02/2021 (Mandatory in NH) E.L. DISEASE- EA EMPLOYEE $ 100,000 If yes. describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of AGORD The Commonwealth of Massachusetts -,:4A��!/. Department of Industrial Accidents t rl; 1 Congress Street,Suite 100 TAN- Boston,MA 02114-2017 wwn:massgov/diet Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aoolicant Information Please Print Legibly Name(Business/organization/individual):Michael Pierce DBA Pierce plumbing& Renovations Address: 4 Kaycees way City/State/Zip:West Yarmouth, Ma.02673 Phone#: 774-722-3221 Are you an employer?Check the appropriate box: Type of project(required): 1LI I am a employer with employees(fall and/or part-time).* 7. 0 New construction 2.®I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself[No workers'comp.insurance requimd.]t 9. [I Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property.I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.®Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These subcontractors have employees and have workers'comp.insurance? 6.1=I We area corporation and its officers have exercised their right of exemption per MGL c. 14.Q outer 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. tCoatractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees.If the subcontractors 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 veriftcatio I do hereby certir nder the s and penalties of perjury that the information provided above is true and correct. Signature: A Date: 'V/CA1--/ Phone#: 774-722-3221 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#: F Commonwealth of Ma, usetts Division of Registratidt Board of Plumbip.g ti Michael Ar !��� 4 Kaycee&w West Yam oij. 8 Joumeyman(Pllimtr :� PL34718-J 05/01/2022 008093 License No. Expiration Date. Serial No.