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HomeMy WebLinkAboutBLDG-20-006084 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t-r-zr_E) cry MA DATE PERMIT# JOBSITE ADDRESS\\13 CrS"R'r\- Y—.&\ OWNERS NAME GOWNER ADDRESS TYPE OR OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL 0 RESIDENTIAL XI PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:Ej PLANS SUBMITTED: YES D NO 0 APPLIANCES T 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 GENERATOR - irN 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 0 NO [21 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY BOND 0 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 LI 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 h I*: ce wit a erti t prLsionf the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAM x .( LICENSE# (07 SIGNATURE MP 0 MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC # COMPANY NAME Awe.r.'t ADDRESS q-Az1 =yeAleArs,outl. • CITY VA evirt.\*.t STATE t ZIP ° 410( TEL 5t2e)***OS oto eta FAX 508--n5-q440 CELL EMAIL au&aros za.r.vrizzloh. Al\ tom 9,1211- 6,6 tick -001(-- 621 DATE(MUIDDIYYYY) ACRD CERTIFICATE OF LIABILITY INSURANCE Of>/2412019 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 MCGRIFF,SEIBELS&WILLIAMS,INC. NAME• P.O.Box 10265 INC.PHON 800-478-2211 ( Birmingham,AL 35202E-MAIL No.taco: ._. (NC,Ne): ADDRESS: INSURERIE)AFFOROING COVERAGE NAIC3 INSURER A ACE American Insurance Company 22667 INSURED INSURER B:ASSOC.Elec.&Gas Ins.Se m Ltd(AEGISIAA-3190004 UGI Corporation including AmeriGas Propane,L.P. P.O.Box 858 INSURER C:Indemnity insurance Company of North America 43575 Valley Forge,PA 14482 INSURERD ACE Flre Underwriters Insurance Company 20702 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:VHNRBSBO REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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. ._.._._. LTRR TYPE OF INSURANCE JN�SD IWVD; POUCY NUMBER JMMIOD/YYYY) IMMIOOM'YY) =IS A X COMMERCIAL GENERALLIABILI/Y HDOG71568167 07f01/2019 07/01I2020 . HOCCURRENCE ET°RENTED _ S 2,500,000 CLAIMS•MADE n OCCUR g PREMISES ES(Es occurrence) $ 2,500,000 — i MED EXP(Any one person) $ 10,000 — PERSONAL&ACM INJURY S 2,500,000 GEN'LAGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE S 2,500,000 O- POLICY .EC I 0 LOC I PRODUCTS-COMP/OP AGO S 2,500,000 OTHER: ! $ A AUIIOMOBLE UABIUTY cISA H25297830 0710/12019 07/01/2020 I COMBINED SINGLE UMIT (Es aeeide e b 2.500,000 X ANY AUTO 1 I BODILY INJURY(Per person) S OWNED SCHEDULED _-- i, AUTOS ONLY _ AUTOS I fIOdLY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY G4MAGE I _ AUTOS ONLY — AUTOS ONLY _(Per accident)._ I S B UMBRELLALIAB OCCUR )(L512E008P 07/0112019 07101/2020 EACH OCCURRENCE j S 5,000,000 Aggregates as applicable X EXCESSLIAB X CLAIMS-MADE i AGGREGATE_._�,.. I$ ___. 5,000,000 CEO RETENTIONS R tt S C E EMPSLOYERS'UABIILJTY YIN WLR C6589712A((CA,MA) 07/0112019 07/01/2020 X S ATUTE 1 OER D i ANY PROPRIETOR/PARTNER/EXECUTIVE WLR C65897167(I-(VAC.Energy EL EACH ACCIDENT S 2,000,000 I OFFICER/MEMBER EXCLUDED? NIA Services) I(Mandatory In NH) V&RC65897088(AOS) E.L DISEASE.EA EMPLOYEE $ 2,000.000 If yes deco-he under 2,000,000 'DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ S S 1 $ S . S DESCRIPTION OF OPERATIONS 1 LOCATIONS(VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more apace Is required) If required by written contract,additional insured status is provided to an y person or organization that the Named Insured has agreed in a written contract to Include as an additional insured for liability arising out of bodily injury or property damage from the Named Insured's operations,provided such contract was agreed to prior to loss. Additional Insured status does not apply to Workers'Compensation. Additional Insured endorsements on the above policies: Automobile Liability: Additional Insured-Designated Persons or Organizations Endorsement DA-9U74b(06/14) Additional Insured-Lessor CA2001 (10/13) (continued next page) 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. For Informational Purposes Only AUTHORIZED REPRESENTATIVE Page 1 of 2 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD