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HomeMy WebLinkAboutBLDP&G-21-002059 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 9raelia p. CITY YARMOUTH MA DATE 10/19/20 PERMIT# BLDP-21-002059 : 1�:Sz:s _. _; JOBSITE ADDRESS 31 MOCKINGBIRD LN OWNERS NAME SOUNDVIEW REALTY TRUST P OWNER ADDRESS CHARLES V ZAHIGIAN TRUSTEE 1 YANKEE DR SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES -I 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❑ 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. SIGNA,URE 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 ANDREW LEVESQUE LICENSE 1;5162 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME HARWICHPORT HEATING AND ADDRESS 461 LOWER COUNTY ROAD COOLING CITY HARWICHPORT STATE MA ZIP 02646 TEL FAX I I CELL —I EMAIL andy@hphclIc.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES' 1 Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES M UjA phCkC I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK = `=e. CITY/TOWN WEST YARMOUTH MA DATE 10/7/2020 PERMIT 3 oe-g/- oc9 YYX_v� �t JOBSITEADDRESS 31 MOCKINGBIRD LANE OWNER'S NAME ZAHIGIAN p OWNER ADDRESS 31 MOCKINGBIRD LANE TEL 508-292-8162 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL ❑ RESIDENTIAL IX PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: IN PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 1 FLOOR--+ 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/OILISAND SYSTEM • DEDICATED GREASE SYSTEM I` DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR AREA DRAIN is INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE!MOP SINK TOILET URINAL WASHING 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 MGI_. Ch,142 YES [YNO Q I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I, ' OTHER TYPE INDEMNITY Q 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 LI 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 knowtedge and that ail 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. ' d�-e. PLUMBER-GASFITTER NAME Andrew Levesque LICENSE# PL15162 GNAT: MP MGF ❑ JP 0 JGF ❑ LPGI ❑ CORPORATION Olt PARTNERSHIP n# LLC I2(# 3944 COMPANY NAME Harwich Port Heating & Cooling LLC ADDRESS 461 Lower County Rd CITY Harwich-Port STATE MA zip 02646 TEL 508-432-3959 FAX 508-432-6075 CELL 508-958-4874 EMAIL andy@hphcilc.com kecia@hphcllc.com 1f -- - f 7 i l E The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 ' ii._ 600 Washington Street Boston,MA 02111 www.mass.gov/dia t Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly i i Nance(Business/organization/individual): Harwich Port Heating&Cooling LLC Li oil- Address: 461 Lower County Road k City/State/Zip: Harwich Port MA 02646 Phone#: 508-432-3959 4 Are you an employer?Check the appropriate box: Type of project(required): 1.2 I am a employer with 75 4, 0 I am a general contractor and I 6. [�New construction j employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 2 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition workingfor me in anycapacity. employees and have workers' �, t p t3' # 9. ©Building addition [No workers'comp.insurance comp.insurance. re required.] • 5. ❑ We are a corporation and its 10.2 Electrical repairs or additions q officers have exercised their 11. Plumbingrepairs or additions 3.❑ I am a homeowner doing all work � p � [iii 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' 13.2 Other HVAC 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. tContractors 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: Selective Insurance Company of South Carolina Policy#or Self-ins.Lie.#: WC9059813 Expiration Date: 10/26/2020 Ij Job Site Address: 31 MOCKINGBIRD LANE City/State/Zip: WEST 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a flue 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 insuranc coverage verification. g. il Ida hereby cere nd ' ar dpenalties of perjury that the information provided above is true and correct. Signature: Date: 10/7/2020 • Phone#: 508-432-3959 Official rrse only. Do not write in this area,to be completed by city or town official. 1 City or Town: Permit/License# _ Issuing Authority(circle one): 1.hoard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1 6.Other • . Contact Person: Phone#: V l 1 4 t.") . k.,.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' CITY YARMOUTH MA DATE October 19,2020 PERMIT# BLDP 21 002059 JOBSITE ADDRESS 31 MOCKINGBIRD LN OWNERS NAME SOUNDVIEW REALTY TRUST G OWNER ADDRESS CHARLES V ZAHIGIAN TRUSTEE 1 YANKEE DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES 0 NO 0 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 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❑ 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. 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 LEVESQUE LICENSE# 15162 SIGNATURE MP© MGF 0 JP❑ JGF 0 LPGI 0 CORPORATION 0# _ PARTNERSHIP 0# LLC ❑# COMPANY NAME: HARWICHPORT HEATING AND COOLING ADDRESS. 461 LOWER COUNTY ROAD, CITY HARWICHPORT STATE MA ZIP 02646 TEL FAX CELL EMAIL andy@hphcllc.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTIGfv NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ FEE:$ PERMIT# PLAN REVIEW NOTES Eivt, [Pt h p he „cv C- or\k_ _ . _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' -4r# k 1 CITY WEST YARMOUTH MA DATE 10/7/2020 PERMIT# /006 . JOBSITEADDRESS 31 MOCKINGBIRD LANE OWNER'S NAME ZAHIGIAN G OWNER ADDRESS 31 MOCKINGBIRD LANE TEL 508-292-R 162 FAx TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL [1 RESIDENTIAL LX PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: LK PLANS SUBMITTED: YES 3 NO APPLIANCES -1 FLOORS 1 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES L"NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY K7 OTHER TYPE INDEMNITY ❑ BOND n 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 I I 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4-/)if-'- - ( --- PLUMBER-GASFITTER NAME Andrew Levesque LICENSE # PL15162 GNATU MP 0 MGF Z JP ❑ JGF ❑ LPG! I I CORPORATION ❑ # PARTNERSHIP [1 # LLC [ '# 3944 COMPANY NAME Harwich Port Heating & Cooling LLC ADDRESS 461 Lower County Rd CITY Harwich Port STATE MA ZIP 02646 TEL 508-432-3959 FAX 508-432-6075 CELL 508-958-4874 EMAIL andy@hphcinc.com ! '1.' OCT 15 2020 tl C 1.