HomeMy WebLinkAboutBLDG-21-002919 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
k.116)1 CITY YARMOUTH MA DATE November 20,202( PERMIT# BLDG-21-002919
JOBSITE ADDRESS 117 PAWKANNAWKUT DR OWNER'S NAME LASHWAY LEE H
G OWNER ADDRESS RFD 94 AUDUBON RD LEEDS MA 01053 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ 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 1
DRYER
FIREPLACE
FRYOLATOR
FURNACE 2
GENERATOR 1
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
OTHER 2
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 David Duverger LICENSE# 18252 SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: DAVID J DUVERGER ADDRESS. 26 DOVE LN,
CITY WEST YARMOUTH STATE MA ZIP 026731414 TEL
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
614-- G(il/p,(rf az4 c=ip THIS APPLICATION SERVES AS THE PERMIT El El
1 FEE:$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�/ DDT[9
�;1a_.�� CITY Yarmouth MA DATE 111512020 �PERMIT#
JOBSITE ADDRESS I117 Pawkannawkut Dr -"OWNER'S NAME John Aubin
GOWNER ADDRESS I--- —!TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES 1 NOQ
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _ M A'
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER 1
DRYER i—
FIREPLACE _�� --
FRYOLATOR
FURNACE -- -------
GENERATOR f1111.1.1111111111
_GRILLE _
INFRARED HEATER ,
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN =6.1:
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT _
TEST
UNIT HEATER —
UNVENTED ROOM HEATER _
WATER HEATER —
OTHER
fire pit s
BBQ 1
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 accu to to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i plia ' aII`Jertinen rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME iDaivid OuVerger I LICENSE 418252 IG ATUR
MP MGF I JP E JGF❑ LPGI❑ CORPORATION OS PARTNERSHIP LJ#[ j LLC❑#
COMPANY NAME:david duvarger I ADDRESS 26 Dove In. R F. C E I V E 0 I
CITY West Yarmouth I STATE ma I ZIP 02673 ITEL
NOV I. 01020
FAX 7 CELL 5089442027 (EMAIL dUVer9&26 t
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' The Commonwealth of Massachusetts
t. =
Department of Industrial Accidents
•viell[m I Congress Street,Suite 100
=1I* Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE PILED WITH THE PERMITTING AUTHORITY.
Maslicant Information Please Print Lesibly
Name(Bwiness/Orgeaization/individual): /?()v 1r--
Address: 2(, DnUG Lti
0,73
City/State/Zip:U/, o Tin h B Phone#: 5—a T-
Are yes an employer?Check the appropriate box:
Type of project(required):
I.❑I am a employer with employees(full and/or part-time)." 7. ❑New construction
2.71-41 a sole prmittro partnership and have no employees working for me in 8.BRemodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself[No workers'comp hta. trance required] 9. Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property.I will 10❑Building addition
ensue that all connectors either have workers'compensation inwaaoce or are sole - 11.0 Electrical repairs or additions
proprieora with no employee& 12.❑Plumbing repairs or additions
5.0 lam a general contractor and I have hired the sub-contractors listed on the attached sheet
These sub-contractors Zors have employees and have worksns'coop.insurance? 13.0 Roof repairs
6.❑We are a oorporetion and its officers have exercised their right of exemption per MCA.a 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insunmce inquired.]
'Any applicant that checks box#1 must also fill one the section below showing their workers'compensation policy information
t Homeowners wM submit thin affidavit indicating they are doing all war and than hire outside cmtracton must submit a new affidavit indicating such
?Contractor,that clack this box must attached an additional sheet showing the mane of the sub-contractors end state whether or not those entities have
employees.If the me-contractors have employees,they must provide their workers'comp.policy number.
I ton 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.Lie.#: Expiration Date:
Job 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 punichnhle 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 under a pains and penalties of perjury that the information provided above is true and correct
Signature: � �/✓./ Date: ley/. . -a
Phone#: )dr-
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#:
. V
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