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Home My WebLink AboutBLDG-21-030271 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Z.-110fCITY YARMOUTH MA DATE December 09,202( PERMIT# BLDG-21-003271 JOBSITE ADDRESS 87 HEMEON DR OWNER'S NAME FINLEY JOEL H II G OWNER ADDRESS PO BOX 1000 SANDWICH MA 02563 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 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 1 FIREPLACE FRYOLATOR FURNACE 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN 1 POOL HEATER • ROOM I SPACE HEATER . ROOF TOP UNIT TEST _ UNIT HEATER • UNVENTED ROOM HEATER • _ WATER HEATER 1 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 11 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© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: COASTAL MECHANICAL ADDRESS. 21 L Fruean Ave, CITY WAREHAM STATE MA ZIP 025711324 TEL FAX CELL EMAIL lisata7coastalphc.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES _ Yes No Ok 149/2_0 �O c Fr THIS APPLICATION SERVES AS THE PERMIT ❑ CI AG c5 O? 143 FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK !a �- CITY West Yarmouth MA DATE 12/8/2020 PERMIT# JOBSITE ADDRESS 87 Hemeon Drive a,.. OWNER'S NAME Joel Finley G __. OWNER ADDRESS PO Box 1000-Sandwich,MA 02563 1 TEI� 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 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR FURNACE 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN 1 POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 3uILL _. 1 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 J AGENT Li 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. /4-&, de PLUMBER-GASFITTER NAME Troy Gilbert LICENSE# 13573 NATURE MP / MGF JP JGF LPG' —1 CORPORATION # PARTNERSHIP # LLC # 4350 COMPANY NAME: Coastal Mechanical ADDRESS 21 L Fruean Ave CITY South Yarmouth I STATE MA ZIP 02664 3TEL 508-737-8747 FAX CELL 508-850-6955 EMAIL lisa@coastalphc.com 6/ • COMMONW ALTH OF M C�-11 $ETF A.;`' DIVISION OF PROFESSIONALLICENSl1RE PLUMBEF AN1 GASFiTTgi' �k 3 x3 * ISSUESTHE FOLLOWNG1J6ENSE , IV E G STEREq,,P IJmat::44 CO�, t�` ~tiyr, N, :ia 9i J GILBERT z : . • CO/ A J U .. NSALP . AND HEAP C i ; 39 r , ET •a . - i WZ ; ,i ' r' r, AREHAM,MA 2571 ';14, l'h t `'•' \fi . I 43$0; ;�,44 ,� 05101J2022:w 856115 LICENSE NUMBER EXPIRATION.�DATE SERIAL NUMBER $ ' ' OMMO W LTH OF M i ‘" le.,— e g;:-�� It• DIVISION OF PROFESSIONAL LICENSURE or ;bi:. :c SO Q , , PLUMBERS NbGASFIT'dTERS r' `:T' a ISSUES<Th.E<=OLLOW1NG I_1dLNSIr a:' 'rii• '1 X. <;:`. J t1RNEYMAP,l' ER ':y..,g, ,.,, ,Pg z> . T Y J GILBERT --{,'4''''`�u r .•, ,t R •r• «� 3 '�re cn I :a '•TNT 1` r. "� ?s;' , :EJ I ,ri g S� 'ATION;.,S:T�;<a,, { , ., -f,. m.; I WAREl P�11ff;,Ml4 0 570 .tor, ti. a �... :t�SS"�'.- `y. ,^,;•t.;k,°9 i. ,,. ,ins:>:�it ' 25383 o t"••- 1011202 ,:� 831568 14. ,,,,,..040 a Y x k Li LICENSE NUMBER . '.EXPIRATION DATE v SERIAL NUMBER ^; 81 CONT ROL#. J 014 6 2 7 4 CONTROL# tJ 414 3 8 2 ; IMPORTANT IMPORTANTIf.your ed or destroyed:is inaccurate;o+ if your license is lost damag ovldpl for a or destroyed;is inaccurate;or � visit our web site at mass' I needs obelicense Is lost,damagedto be corrected, aping of your Renewal needs to corrected,visit our web site at Renewalpi for sure the p p ridence. instructions to ensure the proper mailing of y instructions to en other•correspo Application and any other correspondence. Application and any Massachusetts General laws and j lice to Massachusetts General La`n's and this This license is subl rlvllege,and cannot be lent or This license is subject e regulations.Your lin Snort os ply under penalty o t b a�d�opr regulations.Your license Is a privilege,and cannot be lent or assigned to any Per or posted as required by license to any person or entity under penalty°law and/f law. or this license on your person license on your person or posted as required by i regulations. ' regulations. • Client#:764315 2COASTALPLI ATE(MM/DD/YYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE 0 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: The Hilb Group of N.E.dba PHONE 508 775-1620 FAX (A/C,No,Ext): (A/C,No): 5087781218 Dowling&O'Neil Insurance Agy - E-MAIL P.O.Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC* INSURERA:Evanston Insurance Company 35378 INSURED INSURER B:A.I.M.Mutual Insurance Company 33758 Coastal Plumbing&Heating LLC SafetyCompany Dba Coastal Mechanical INSURER C: Insurance Com an 39454 299 Whites Path INSURER D: South Yarmouth,MA 02664 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 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 ADDL SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER (MM/DD/YYYYL(MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY MKLVIPBC000737 01/04/2020 01/04/2021 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR PREMISES(Ea oN Wince) $100,000 X BI/PD Ded:5,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 O POLICY Si Tar- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: C AUTOMOBILE LIABILITY 5906835 01/04/2020 01/04/2021 Ea COMaBccident)ident) $1,000,000 NGLE LIMIT ( ANY AUTO BODILY INJURY(Per person) $ OWNED Si AUTOS SCHEDULED AUTOS ONLY BODILY INJURY(Per accident) $ HIREDON-OWNED PROPERTY DAMAGE Si AUTOS ONLY SiX AUTOS ONLY (Per accident) $ $ A UMBRELLA LIAB OCCUR MKLVIEUL102215 01/04/2020 01/04/2021 EACH OCCURRENCE $1,000,000 X EXCESS LIAB X CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION$ _ $ B WORKERS COMPENSATION WMZ80080074082020A 01/04/2020 01/04/2021 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E_L.DISEASE-POLICYLIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 191,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 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 134 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ~707 ©9988 20 ACORD ORATION.All rights reserved. ACORD 25(2016/03) 1 of I The ACORD name and logo are registered marks of ACORD LSI #S251644/M251588 • \ The Commonwealth of Massachusetts - 1 Department of Irnlustrial Accidents • I Congress Street,Suite 100 Boston, MA 02114-2017 ' www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TORE FILED WiTH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual):COaStal Mechanical Address: 21 L Fruean Ave City/State/Zip:South Yarmouth, MA 02664 Phone#: 508-737-8747 Are you tin employer?Check the appropriate box; Type of project(required): am a employer with employees(full and/or part-titre)." 7. [VIew construe lion 2.❑i um a sole proprietor or partnership mid have no employees working for Inc uh 8, Mtemodeling nay capacity,(No workers'romp.insurance required.) 9. ❑Demolition 3.0 I am a homeowner doing all work myself.(No workers'comp.insurance required.]t 10❑Building addition 411!inn n homeowner and will be hiring contractors to conduct all work on my property. twill / ensure that nil contractors either have workers'compensation insurance or are sole 1I,J�,I'f lectricnl repairs or additions proprietors with no employees. 12, Plumbing repairs or additions 5.0 l ion a general contractor and I have piled the sub-contractors listed or the attached alma 13. Roof repairs These sold-contractors have employees and have workers'comp.insurance., �/ p 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. i 4.Lid ether HV C 152,¢I(4),and we have no employees.(No workers'comp.insurance required., "Any applicant that checks box!!I must also fill out the section below showing[heir workers'compensation policy irtfonnation. I.Homeowners who submit this affidavit indicating they rue doing ull work and then hire outside contractors must submit a new affidavit indicating such. ,Contractors that check this box truant clinched an additional sheet showing the name of lie sub-contractors and state whether or not those entities have employees. If the subcontractors have employees,they mast provide their workers'comp.policy number. I am an employer that is providing workers'compensation insnrarrce for my employees. Below is the policy and job site information. Insurance Company Name: AIM Mutual Policy#or Self-ins.Lic.#: WMZ80080074082020A Expiration Date: 01/04/2021 Job site Address: : 87 Hemeon Drive City/state�zip. W. Yarmouth, MA 02673 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 aphis(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 larder the pains and penalties of peajuty that the information provided above is true and correct. „1/164- Date: 12/8/2020 Phone II: 508-737-8747 Official use only. Do not write in t/ils area,to be completed by city or town official, City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2,Building Department 1 City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other 3 Contact Person: Phone it: