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HomeMy WebLinkAboutBLDG-21-004628 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE February 16,2021 PERMIT# BLDG-21-004628 JOBSITE ADDRESS 441 ROUTE 6A OWNERS NAME SUMMERFIELD MARTIN A G OWNER ADDRESS SUMMERFIELD MARGO T 441 MAIN ST YARMOUTH PORT MA 02675-1824 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 1 _ 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 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 Gary Famigliette LICENSE# 10191 SIGNATURE MP© MGF ❑ JP 0 JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: GARY FAMIGLIETTE ADDRESS. 67 MAPLE AVE, CITY HYANNIS STATE MA ZIP 026014403 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =1 i— _" CITY �- --. -- Ljr1.''''�. . 1: MA DATE iky / �( PERMIT# (-D6 2(--v0 1�1� JOBSITE ADDRESS - "� 7_ / /-4---_. OWNER'S _ - -- OWNER'S NAME C 6 iU ec� �14^ G OWNER ADDRESS - .- _ . .6. ( TEL IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL: j EDUCATIONAL U RESIDENTIAL /Y PRINT CLEARLY NEW: ,I RENOVATION: . REPLACEMENT:' PLANS SUBMITTED: YES U NO_.[ APPLIANCES 1 FLOORS-► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .i,__-_I I.____ .._____J 1 _-__.-_I _:-___,_____J ____I ____J________ J __-__ BOOSTER I ! I 1 t I ,_J. —.I —_1. I .— _1 -___I CONVERSION BURNER i I I I I I.�� I _ i _J �I __I _I __ _ _I COOK STOVE � I I _____-____I +. 1 ___# ___ I —I .__—C _____I _ _I _I, DIRECT VENT HEATER � ( �-- I _j — — J I I s DRYER • --- . ._..... I -.. ._ . .. . _.. _ . _Ti ` _____J —_J_._.___1 I ! I I I ____I I ____.1 I i _1 _..1 .___.1 I k) FRYOLATOR I ___..., 1 I ___ I _____I + ► I __J ( ___I FURNACE __ I I I I _ ! I I I _. I _ J I 1 GENERATOR ..._._ I ; I i I I I .�._._! —.! _.,._1 ____I -- , �r.rM GRILLE I I . r .. . t I 1 1 __. I _____! 1 I __-.1 _I _I i -J ---- I —J __ _.._ _r__1 ' INFRARED HEATER LABORATORY COCKS 1 - } i _. .._._.___I 1 . - I I I ______I I _.____1 .-.a . i _ MAKEUP AIR UNIT f .. .. - 1 _ : .------- I I ___,I __I _.r.I .. __I __I __._�.. 1 .._.___ _ ....._____ _____I . _..._i, ____.t kOVEN �I _.�...__! _,-___-�± I 1. °�__-__I .___. ._I _...__I _ . ...._:-.i .__._..I __.._....1 POOL HEATER -._._I _____I _,_ __I _ I -._.._I ______1, ROOM 1 SPACE HEATER I ! _i . .. f f _w._.-j j w_I . . i _� I _ I - ` - I - - ROOF TOP UNIT _...,.._.__ t , � - -- -_._. .�...�.. I .._.-I ), 1 _I _i .__..,._! �I I I 1 . I I TEST .._i I i << ` ___-_i ._.__-_...I . 1-_ i _i _ I _ _ UNIT HEATER I I �! } .i � • • ---, ---E _.: UNVENTED ROOM HEATER WATER HEATER I l I OTHER ` _. -I ._ . . . � -�-----I - •-�� . . I - • I I i f .-_.__..I ! .. ....._... I _.__.� = -- _.__._....t ' ' _I _.._._ _I I _.._....I c _1 f ! __ r INSURANCE COVERAGE CI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ,INO 1 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _ OTHER TYPE INDEMNITY :LI BOND III 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 — 1 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 accurte to the best of my knowledge ' and that all plumbing work and installations performed under the permit issued for this application will be in complian with itil Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME C'A' cA \ 1 d, . " 7 ��+�_-' ��' — LICENSE # / �/ SIGNATURE MP MGF ,^1 JP JGF LPG! CORPORATION # PARTNERSHIP t# - - y LLC #` - COMPANY NAME: ` /1 r l(Q I ADDRESS d '7 v44.16110 v- e CITY 1-4-Li r Ife - J STATE V I ZIP D` GG 1 TEL . k-- _ 7-7 c M FAX !EMAIL:. - - . - - . _ _ � -- . . _ _.__ . ._. _ _. ___..._ .---__....CELL: E—F ,�,� �'v. . .. - co:n (ems . • lice . The Commonwealth of Massachusetts . it Department of Industrial Accidents , : _ Office of Investigations { r ; 600 Washington Street . Boston,MA 02111 www.mass.gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): i� � �, 1 Name t{G k _ 6(t,, y_At 1 c c. >j Address: U-7 'A- cx V I-e ��(.3 '�' ! . CitylState/Zip:C4 to n t S 11�IU. 0,460 1 Phone#: .. �'-j'-° " ." 4), Are-you an employer?Check the appropriate box: Type of project(required): l. _ 1 am a employer with 4° I am a general contractor and I ' have hired the sub-contractors �' New constntctioo • inplvyces,(full and/or part-time).* • ' T ant it sole proprietor or partner- listed on the attached sheet. 7. Remodeling - 'ship and have no employees These sub-contractors have g; Demolition working for me in any capacity. employees and have workers' 9. Building addition • [No workers'comp. insurance comp. insurance.$ required.] _ 5. We are a corporation and its 10. Electrical repairs or additions 3. • 1:am a homeowner doing all work officers have exercised their I l. Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12. Roof repairs insurance required.]t c. 152,§1(4),and we have no - employees. [No workers' 13. Other 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. .1Contractors 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 my employees. Below is the policy and job site . . irr farmation. •lnst,►rance Company Name: . Policy#or Self-ins.Lic.#: Expiration Date: ^• • Job 5ife Address: City/State/Zip: '' Attacit a•copy of the workers' compensation policy declaration page(showing the policy number and expiration date). - 1'ailurcl to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a line 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of • Investigations of the DIA for insurance coverage verification. Am I do jiereby cer(ify unde the pains and penalties of perjury that the information provided above is true and correct. • Signature: c Date: ►`-)',..'2j11 • Phone#: 5 t� E'_) 7 -7$— b 5 . 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 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector - - 6.Other • ' Contact Person: Phone#: