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Home My WebLink AboutBLDP&G-21-004246 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 4 CITY FARMOUTH MA DATE 1/29/21 PERMIT# BLDP-21-004246 JOBSITE ADDRESS 524 ROUTE 6A OWNER'S NAME VISHAL and DIPTI SHUKLA P OWNER ADDRESS 1 PATRICKS WAY FORESTDALE 02644 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ FIXTURES 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 CCNNECTION 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 ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE 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. SIGNATJRE 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 [Troy Gilbert LICENSE t3573 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME COASTAL MECHANICAL ADDRESS 21 L Fruean Ave CITY WAREHAM STATE MA ZIP 025711324 TEL FAX 7 CELL EMAIL lisa@coastalphc.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES + Yes No THIS APPLICATION SERVE AS THE PERMIT FEES$ PERMITS PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS-FATS WORK t‘. =no CITY Yarmouth Port ..__ MA DATE 01/1912021 PERMIT # 7 /9`'1 GV JOBSITE ADDRESS 524 Route 6A „b.,.....�.�..,_,,.,� , OWNER'S NAME [Vishal and Dipti Shukla I GOWNER ADDRESS 1 Patricks Way Forestdale, MA 02644 I TEL FAX,_ _ TPR �R OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY .. NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES' NO' APPLIANCES Z 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 -.Jr: .J ___ --._ FRYOLATOR LI FURNACE GENERATOR I I _ 3:-., GRILLE INFRARED HEATER ___ .� -0.0,0,; . . LABORATORY COCKS MAKEUP AIR UNIT OVEN I.... _._., �._._ . .. �. .. POOL HEATER ----- -- ._, — . -Lthi ROOM / SPACE HEATER ROOF TOP UNIT TEST __.,,. �._.T.., UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 �. _� -u OTHER �;; V INSURANCE COVERAGE a, " I I have a current liabiliiyinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO 1 I IF YOU CHECKED YES. PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 3 1 JAN 20 2021 LIABILITY INSURANCE POLICY / OTHER TYPE INDEMNITY BOND ��._.� yt ►lLf?$Nf DEPARTMEN 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7:Le3",/de PLUMBER-GASFITTER NAME 'Troy Gilbert LICENSE #, 13573 GNATURE MP " MGF JP JGF ® LPGI J CORPORATION L# l . .... A PARTNERSHIP L^ # 1 LLC # 801 COMPANY NAME:[Coastal Mechanical ADDRESS 21 L Fruean Ave CITY South Yarmouth ¢ STATE MA ZIP 02664 I TEL 508-737-8747 FAX CELL[508-850-6955 BALI lisa@coastalphc.com , , , • • 141 - The Commonwealth of Massachusetts (1 — 1. Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 s'' Www.mass.gov/dia 1.11' Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE 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 an employer?Check the appropriate box: Type of project(required): I. '1 ran a employer with 30 employees(full and/or part-time)." 7. 'New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity (No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.(No workers'comp.insurance required.]t 10[]Building addition 4.0 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 II11.EVElectrical repairs or additions proprietors with no employees. 12.SiPlumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.[ 14.tiOther Hvac 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. ` 152,§1(4),and we have no employees.(No workers'comp insurance required.] °Any applicant that checks box tit must also till 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 1 am an employer that is providing workers'compensation insurance for rap employees. Below is the policy and job site information. Insurance Company Name: Hartford Finacial Services Group Policy#or Self-ins.Lic.it: 08WECAJ7RT4 Expiration Date: 12/31/2021 Job Site Address: 524 Route 6A City/State/Zip: Yarmouth Port, MA 02675 Attach a cop)of the workers'compensation policy declaration page(showing the policy number and expiration date). 6 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 1 coverage verification. I do hereby cer ' under the pain's and penalties of peijuly that the information provided above is true and correct. Signature: C /v,6,E Date: 01/19/2021 Phone#: 508-737-8747 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 it: I I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK sY BL 21-004246 a-� -6 CITY YARMOUTH MA DATE January29, 2021 PERMIT # �'` JOBSI"E ADDRESS 524 ROUTE 6A OWNER'S NAME VISHAL and DIPTI SHUKLA G OWNER ADDRESS 1 PATRICKS WAY FORESTDALE 02644 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: El 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 l 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 ❑ 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. SIG NATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered -egarding 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 Plumb ng Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Troy Gilbert LICENSE # 13573 SIGNATURE MP © MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME: COASTAL MECHANICAL ADDRESS. 21 L Fruean Ave, CITY WAREHAM STATE MA ZIP 025711324 TEL FAX ] CELL EMAIL lisana,coastalphc.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE:$ PERMIT# PLAN REVIEW NOTES i i MASSACHUSETTS UNIFORM APPLICA TION FOR A PERMIT TO PERFORM GAS FITTING WORK 4 —__- -. PERMIT # `� " - g---7) L/2/ * ; CITY Yarmouth Port ----- MA DATE 01/19/2021 JOBSITE ADDRESS 524 Route 6A .. ,,.w � .:..__- ,..w.,��; OWNER'S NAME Vishal and Dipti Shukla______J FAX TEL ., ,_ ... - GL-1Forestdale, MA 02644 OWNER ADDRESS Patricks Way - - - TYPE OR EDUCATIONAL 1 RESIDENTIAL PRINT OCCUPANCY TYPE COMMERCIAL CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER MN PIM MINIIIIIIIMIl — 11111101111M �_ CONVERSION BURNER — MIIIIIIMPIMINIMIIII -- COOK STOVE __ DIRECT VENT HEATER MI MI DRYER 11111111.111111111 •111111111101111111111111111111 --- 1'� MI WO IMPS OM 10.11 FIREPLACEummili —mommineum FRYOLATOR1111111111111111 FURNACE — ITIMENIA — __ PIIII GENERATOR O 110011 iT_—� �_ IPIIIIIWIIIIIOIIIIIIIII Will GRILLElin � � —_ �.- INFRARED HEATER _ LABORATORY COCKS 111111111111111111.11=11.11•111111� 1111j1 WWI MAKEUP AI R UNITINN OVEN POOL HEAT ER IIIIIMINIMI IMINI11=11111M1111111.1 111111 — ROOM 1 SPACE HEATER 1111111.11111111111111111.1 ;,` -1111110111111.11111 OM�� NM ROO IIIIIMIIIIIIIIII TEST � _IMMI UNIT HEATER � _ _ MEE Mill UNVENTED ROOM HEATER MEIN � - - , —�_ _ 11.1 TER HEATER 01111011111M 11011M101111111 OTHER . . 1.111.1. WWII ma miumeimumm - — 1111.11gm um _ __ ow tommaming 111.1111101 Ilirk 1111111M. 1101, so maammemmai ,1 mom moms _____ _ INSURANCE COVERAGE substantial equivalent which meets 't41 ""YES � NO I have a current liabili�insurance policy or its the requirements of MG . C .q 2021 - INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW JAN 20 , I IF YOU CHECKED YES, PLEASE } POLICY OTHER TYPE INDEMNITY a PAn.` e_ w LIABILITY INSURANCE BUILDIN OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage requir by C-heter 142 of the — - .. Massachusetts Generai Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [' AGENT E SIGNATURE OF OWNER OR AGENT are true and accurate to the best of my knowledge I hereby certify that all of the details and information I have submitted or entered regarding this application in work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the and that all plumbing �� L�f'.11 e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. At— PLUMBER-GASFITTE�� NAME Tro Gilbert LICENSE # 13573 SIGNATURE CORPORATION � #__._ PARTNERSHIP# LLC ,��1#1 801 MP � MGF JP Li JGF � LPGI -�,� �.. COMPANY NAME:LCoastal Mechanical ADDRESS 21 L Fruean Ave . M.,:,_ ...;,. . - -, , STATE MA ]TEL ' y ZIP 02664 508-737-8747 CITY South Yarmouth FAX I CELLL508-850-6955 kMAlLtlisa@coastalphc.c0m .-,.,. ,� �—u,r _,N ;: .._;..._�. � i T � ACC) ?f� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) � 01/06/2021 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 Tina Reeves Dowling & O'Neil Insurance .agency PHONE (800) 640-1620 FAX No : (A/C, No, Ext): ( ) 973 lyannough Road E-MAIL treeves@doins.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # Hyannis MA 02601 INSURER A : The Hartford Financial Services Group 91 INSURED INSURER B : Coastal Plumbing & Heating LLC INSURER C : Dba Coastal Mechanical INSURER D : 21 L Fruean Way INSURER E : South Yarmcuth MA 02664 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. ADDL SUBR POLICY EFF POLICY EXP TR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 ,000,000 DAMAGE TO RENTED 1 ,000,000 CLAIMS-MADE X OCCUR PREMISES (Ea occurrence) $ MED EXP (Any one person) $ 10,000 A 08SBAAJ7RXH 12/31/2020 12/31/2021 PERSONAL & ADV INJURY $ 1 '000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 JECT $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1 ,000,000 A EXCESS LIAB CLAIMS-MADE 08SBAAJ7RXH 12/31/2020 12/31 /2021 AGGREGATE $ 1 ,000,000 DED X RETENTION $ 10,000 $ WORKERS COMPENSATION X STATUTE EOTH AND EMPLOYERS' LIABILITY 1 ,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N E.L. EACH ACCIDENT $ A` OFFICER/MEMBER EXCLUDED? N N / A 08WECAJ7RT4 12/31/2020 12/31/2021 1 .000 000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ ' If yes, describe under 1 000 000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ ' ' I I I l — I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, 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 thecoverage provided by the policy provisions. 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. Town of Yarmcuth Town Hall; 1146 Route 134 AUTHORIZED REPRESENTATIVE South YarmoLth MA 02664 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD