The URL can be used to link to this page

Home My WebLink AboutBLDG-23-003711 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE January 09,2023 PERMIT# BLDG-23-003711 JOBSITE ADDRESS 31 HAWKS WING RD OWNERS NAME GREAT WESTERN ROAD LLC G OWNER ADDRESS P 0 BOX 25 CHATHAM MA 02633 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:D 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 FIREPLACE FRYOLATOR FURNACE GENERATOR 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 1 ROOM I 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 Andrew Mikita LICENSE# 18843 SIGNATURE MP 0 MGF❑JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ANDREW J MIKITA ADDRESS. 48 INTERVALE LN, CITY S HARWICH STATE MA ZIP 02661 TEL FAX - CELL EMAIL none l ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No Oh 21 It /L 3 C'f THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT# _ PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' - --- -:, -1, CITY So,-•k+ /ct/t.44 ec. � MA DATE i ( 6 ( c ; PERMIT# 2-3 — -7/f r JOBSITE ADDRESS 2 P 'A ti.J 4-S "r N f /ZI OWNER'S NAME AS't/ J l c //ie,Sys C OWNER ADDRESS -__ 3 Gr c✓tey �//'y /Zoe TEL • 7 r - �3�-cia%'I=AX TYPE OR _ " PRINTOCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL I I RESIDENTIAL CLEARLY ' 'NEWY RENOVATION: REPLACEMENT: I I PLANS SUBMITTED: YES D NO ❑ APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 I 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER i —� ,--- —_--__ — COOK STOVE , DIRECT VENT HEATER • ' DRYER FIREPLACE . , FRYOLATOR , F � � E D ,..o ,r• FURNACE - • _�_-- -' •- 1 GENERATOR i GRILLE :AN 0-6 2�3 INFRARED HEATER ' LABORATORY.COCKS t _—� BUILDING tJEPAtRI-ME T MAKEUP AIR UNIT OVEN 1 r _ `„^ .� �__ '-_ O _ POOL HEATER i - . ROOM I SPACE HEATER ROOF TOP UNIT I TEST UNIT HEATER UNVENTED ROOM HEATER • _ WATER HEATER OTHER 1 1 1 1 1 .__.__ ESTIMATED VALUE OF WORK: I , 5'ec9 I IIII I IIIIII i 1 11 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [ I NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COV RAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND [I OWNER'S INSURANCE WAIVER: I am aware that the R censee 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 I ( AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that ail 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 comps' -with all Pe ' ent provisi of he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' 0/ PLUMBER-GASFIT T ER. NAME LICENSE #/g,teif3 NATURE } MP I I MGF ri JP E JGF — LPG! [l CORPORATION ❑ # PARTNERSHIP L_i # LLC L]# COMPANY NAME /44/1(1 /il ?F# ADDRESS B '-K ‘/'6 CITY D /jWW/t.1iSTATE /47 el ZIP .02a Z( TEL leg -13 7 - ` I FAX CELL EMAIL 4AJ / J'iiild T v d c S Mite ; Cm 'W The Commonwealth of Massachusetts "_.!i• Department of Industrial Accidents __` a 1 Congress Street,Suite 100 EiEi Boston,MA 0211 4-2 01 7 • • z _ • www massgov/ilia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TEE PERMITTING AUTHORITY. Anpticant Information Please Print Legibly Name(Business/Organization/Individual): Address: • City/State/Zip: Phone#: Are you an employer?Cheek the appropriate tor. Type of project(required): LID ama employer with employees(fad aad/orpaet-time).° 7. ❑New construction 20 I am a sole proprietor or partnership and have no employes working for me in 8.❑Remodeling any opacity.[No workers'comp.ire required.] 3.01 am a homeowner doing aIwoekmy if.[No work®'comp.insurance regoved)t 9.❑Demolition . 4.0I am a homeowner and will he hiringcoutractors to conduct all work on my property.I will 10❑Building addition emmethatall contractors either have wo.lex'compensation insurance or are mle 11.0 Electrical repairs or additions pmpriefoa with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hoed the sub-conhamon listed on the attached sheet. These sobcoana,ors have employees and have workers'comp.innmacet 13.EIRoofrepairs ' 6.0 We are acotporation and its officers have exercised their right of exemption perNIGLa 14.00ther 152,I1(4),and we henna employees[No workers'comp.insurance required] "Any applicant that checks box M1 must also fill out the section below showing theirwodkas'congeasatioo policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit m sting such tC®hactors that check this box a attachedan additional shoal slowing the acme of the subcontractors and ante whether or not those entities have employes.If de sub-contractors have employee they must provide their workers'comp.policy mailbox 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: lob 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 verification. I do hereby certify under the pains and penalties of perjury that the information provided above is tone and correct Signature: Date: Phone#: Official use only.Da 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#: