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HomeMy WebLinkAboutBLDP&G-18-006273 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t CITY YARMOUTH MA DATE May 08, 2018 PERMIT# BLDP 18 006273 '� JOBSITE ADDRESS 77 LAKEFIELD RD OWNER'S NAME HEALEY JOYCE M 1 G OWNER ADDRESS 77 LAKEFIELD RD SOUTH YARMOUTH MA 02664-2942 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENT:O 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 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 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 Phillip Durfee LICENSE# 13774 SIGNATURE MPLI MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑#, LLC❑# COMPANY NAME' PHILLIP J DURFEE ADDRESS 12 American Way Unit 1, CITY DENNIS STATE MA ZIP 026382417 TEL FAX CELL EMAIL phildurfeeplumbinq.com • • S31ON M3IA321 NVld #111AP:13d $ :33d ❑ ❑IIIN2:13d 3H1 SV S3A233S NOLLVO lddV SIHI oN sa,k S31ON NO11O3dSNI IVNId AlNO 3Sfl bO133dSNI 2IOd 39Vd SIH1 S31ON NOLLO3dSNI SVO HOflO2d yy MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Ham`-i1 CITY South Yarmouth MA DATE 05/03/2018 PERMIT# JOBSITE ADDRESS 77 Lakefield Road OWNER'S NAME Joyce Healey GOWNER ADDRESS 77 Lakefield Road TEL 5083944145 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 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 1 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 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 compli nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Phillip Durfee LICENSE# 13774 SIGNATURE MP MGF JP JGF LPG! CORPORATION # PARTNERSHIP # LLC # 3152 COMPANY NAME: Durfee Plumbing&Heating LLC ADDRESS 2A Huntington Ave. CITY South Yarmouth STATE MA ZIP 02664 TEL 508-619-3078 FAX 508-258-0592 CELL 508-801-8004 EMAIL phil@durfeeplumbing.com;joy@durfeeplumbing.com The Commonwealth of Massachusetts 1 =—_, � /. Department of Industrial Accidents __; ►= 1 Congress Street,Suite 100 = fir <' Boston,MA 02114-2017 \_ / www.mass.gov/dia -„,...4... . Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Durfee Plumbing & Heating LLC Address:12 American Way Unit 1 City/State/Zip:South Dennis, Ma 02660 Phone#:5086193078 Are you an employer?Check the appropriate box: Type of project(required): LID I am a employer with 5 employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. D Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10 0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.�✓ Plumbing repairs or additions 512 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑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. Insurance Company Name:The Hartford Policy#or Self-ins.Lic.#:08-WEC-CQ1525 Expiration Date:04/03/2019 Job Site Address:11 I. oil.,2 f v c- kck City/State/Zip: ICtnil cji \f1 1 NA c‘ O-26(o 1 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 fme 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 fme 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 and a pains and penalties of perjury that the information provided above is true and correct. Signature: �. Date: 5 I.?I y- Phone#: 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#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK x CITY YARMOUTH MA DATE 5/8/18 PERMIT# BLDP-18-006273 a v JOBSITE ADDRESS 77 LAKEFIELD RD OWNER'S NAME HEALEY JOYCE M P OWNER ADDRESS 77 LAKEFIELD RD SOUTH YARMOUTH, MA 02664-2942 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑ PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 _ 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE _ DISHWASHER _ DRINKING FOUNTAIN _ _ _ _ FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) - KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING 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 El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El BOND El 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'S NAME Phillip Durfee LICENSE#3774 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME PHILLIP J DURFEE ADDRESS 12 American Way Unit 1 CITY DENNIS STATE MA ZIP 026382417 TEL FAX CELL EMAIL phil©durfeeplumbing.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES �� y Yes No THIS APPLICATION SERVE AS THE ❑ ❑ DCDMIT FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �rom CITY South Yarmouth MA DATE 05/03/2018 1 PERMIT# f JOBSITE ADDRESS 77 Lakefield Road OWNER'S NAME! yce Healey OWNER ADDRESS 77 Lakefield Road TEL 5083944145 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL RESIDENTIAL '1 PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _ DISHWASHER DRINKING FOUNTAIN jy FOOD DISPOSER '— FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK _ TOILET URINALrWASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 _ WATER PIPING OTHER 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 TYPE 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. 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 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 compliancth all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME;Phillip Durfee I LICENSE# 13774 SIGNATURE MP JP ] CORPORATION # PARTNERSHIP # 1LLC # 3152 COMPANY NAME. Durfee Plumbing&Heating LLC ADDRESS 12 American Way Unit 1 CITY'South Dennis STATE MA ZIP 02660 TEL 508-619-3078 FAX 508-258-0592 CELL 508-801-8004 'EMAIL ,phil@durfeeplumbing.com;sales@durfeeplumbing.com •1. _ a, 4v 3 � }r Accela Citizen Access Page 1 of 1 • • Announcements Register for an Account I koala Need Help?For technical assistance in using this web application,please call the ePLACE Help Desk Team at(844)733-7522 cip or(844)73-ePLAC between the Search... w hours of 7:30 AM-5:00 PM Monday-Friday,with the exception of all Commonwealth and Federally observed holidays.If you prefer,you can also e-mail us at ePLACE helpdesk(rDstate.ma.us.For assistance with non-technical issues,please contact the issuing Agency directly using the links below. Contact Alcoholic Beverages Control Commission Contact Division of Capital Asset Management and Maintenance Contact Department of Labor Standards Contact Division of Professional Licensure Translation Information-Click Here To apply for an Energy and Environmental Affairs(DEP,MDAR or DCR)permit or license,please click here. Document Attachment:In order to upload required documents,this system requires Microsoft Silverlight,which can be downloaded for free here. Convenience Fee:Please note there may be a convenience fee for all online credit card transactions.There is no fee for online payment by check. Home Manage Licenses,Permits&Certificates Flle&Track Complaints Please refer to the Licensing Entity's website for additional information regarding the status and discipline information shown below. For DPL information,please visit the DPL website. For ABCC information,please visit the ABCC website. Information Pertaining To: Master Plumber 13774 Licensee Detail License Number: 13774 Licensing Entity: Board of State Examiners of Plumbers and Gas Fitters License Type: Master Plumber Type Class: M License Issue Date: 04/12/2005 License Expiration Date: 05/01/2020 Status: Current Current Discipline: Prior Discipline: Name: PHILLIP]DURFEE Business Name: DBA Name: ► Public Documents https://elicensing.state.ma.us/CitizenAccess/GeneralProperty/LicenseeDetail.aspx?Licensee... 5/8/2018