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HomeMy WebLinkAboutBLDG-21-002924 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ik,,,, ` CITY YARMOUTH MA DATE November 20,202( PERMIT# BLDG-21-002924 ` JOBSITE ADDRESS 76 HEMEON DR OWNERS NAME KILLEN ROBERT E G OWNER ADDRESS 76 HEMEON DR WEST YARMOUTH MA 02673 __I TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR _ _ _ • GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: l 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 Douglas Langtry LICENSE# 11305 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: DOUGLAS P LANGTRY ADDRESS. 1268 ROUTE 28, CITY S YARMOUTH STATE MA ZIP 1026644459 I TEL ( I FAX CELL EMAIL I 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 �I= 11/5/2020 N YARMOUTH / _• _ CITY MA DATE PERMIT#�( -2I -!�(��i z JOBSITE ADDRESS 76 HEMEON DRIVE OWNER'S NAME KILLEN GOWNER ADDRESS SAME TEL 508-394-4020 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑■ PLANS SUBMITTED: YES❑ NO ■❑ APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 _ 13 14 BOILER 1 BOOSTER CONVERSION BURNER _ COOK STOVE DIRECT VENT HEATER _ DRYER FIREPLACE FRYOLATOR FURNACE 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 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 ❑■ 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 re true and accurate t e be t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in • ce with all P anent rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME DOUG LANGTRY LICENSE# 11305 �P CIVEr MP❑■ MGF❑ JP❑ JGF❑ LPG] ❑ CORPORATION❑# PARTNERSHIP❑# - CCC®# 3U6 COMPANY NAME AQUA SERVICES PLUMBING & HEATING ADDRESS 1200 ROUTE 28 NOV 1 0 2020 CITY SOUTH YARMOUTH STATE MA �t ZIP 02664 t_5b8 (�/ TEL ''17�7��F'AR1 MINT �4 FAX 508-619-3367 CELL �4 EMAIL DOUG-AQUA@COMCASTaNT / 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 The Commonwealth of Massachusetts 4 Department of Industrial Accidents Ai y�'� 5l Office of Investigations ..IIIIIA1.� o� ei is 1'� =,t.�.. : 600 Washington Street lilt Boston, MA 02111 :r„L4. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): AQUA SERVICES PLUMBING & HEATING LLC. Address: 1200 ROUTE 28 City/State/Zip: SOUTH YARMOUTH, MA 02664 Phone #: 508-619-3367 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 4 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ElWe are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. X❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t 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. 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. Insurance Company Name: MARKFI INSURANCF COMPANY Policy#or Self-ins. Lic. #: MWC0145498-02 Expiration Date: 3/19/21 Job Site Address: 76 HEMEON DRIVE City/State/Zip:WEST YARMOUTH MA 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 under the pVeties of perjury that the information provided above is true and correct. Signature: Date: 11/5/2020 l Phone#: 508-A19-336 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#: