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Home My WebLink AboutBLDG-21-003754 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `� _`��— :, CITY YARMOUTH MA DATE January 06,2021 PERMIT# BLDG-21-003754 _ ®�-° JOBSITE ADDRESS 11 OLD SALT LN OWNER'S NAME GUISE C NICHOLAS TRS G OWNER ADDRESS GUISE CATHY C TRS 93 JENKINS RD ANDOVER MA 01810 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL EI 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 1 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 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 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. 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 Gregory Selfe LICENSE# 26714 SIGNATURE MP❑ MGF ❑ JP El JGF❑ LPGI ❑ CORPORATION❑ # PARTNERSHIP ❑# Lc El# COMPANY NAME: GREGORY A SELFE ADDRESS. 41 SPRINGER LN, CITY WEST YARMOUTH STATE MA ZIP 026734930 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 MASSAC:IIUSET 15 UNIt-OKm ArrLft,HI IUN rum. H rcrcivii I I v rcr\rvrsivi vr-‘w Fill 'i,4v vvvr rx = l01 '�4''aQ' PERMIT # /56' D2/ 37sY 7c CITY lv MA DATE JOBSITE ADDRESS 0 1-0 SAS-!I ft N e. OWNER'S NAME Fe <O GOWNER ADDRESS << OLD - - r Le ne TELrg) teg )6 4 FAX - o OJ TYPE OR OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: n RENOVATION: REPLACEMENT , PLANS SUBMITTED: YES ❑ NO n APPLIANCES Z FLOORS-0 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 R E C E I ROOM / SPACE HEATER ~' - - _ • ROOF TOP UNIT I TEST � y'' 4 UNIT HEATER UNVENTED ROOM HEATER DING !LIPARI .7T.— ,:T WATER HEATER l BY. --y- ?--- = OTHER COO k INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES IX NO n I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ] 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 ❑ 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. cJ LICENSE # 6 7" SIGNATURE PLUMBER-GASFITTER NAME 6C&01e7. � c3 Y MP MGF JP JGF LPGI CORPORATION ❑ # PARTNERSHIP n # LLC ❑ # COMPANY NAME 6 °" Se)Ce-PLAs, t""c ADDRESS '11 5e a ose - 19-nc- CITY lA• Yi"I'4t• STATE r4 if ZIP 0 a 6 7 3 TEL FAX CEL Sob) .4"cQ - (3� EMAIL Ce IP I rO y,�-J��d-��,►a, Y k----77-`-4%--:-11 Department ofXrrdurtrialAccidents ., 1 Congress Street,Suite 100 Boston,ZIA 02114 2017 . • y }i�wW.mass go y/diri V Worlcers'.Compensation Insurance Affidavit:Builders/Contractors(Electricians/PInmbers, TO DE PILED WIT]11kiL PEf14TrTIAIG AU1HOIiIIY. APPlicantlnformation Please Print LegibIY Naige(Business/Organization/Individual): Address: • City/State/Zip: Phone#: ' A.r=you a❑empioyca Chcck the appropriate boz Type of project(required): 1-Q I am a employer with employers(full and/orpart time).* • 7. ❑New construction • 7_EllIzin a sot.proprietor or partnership and have DO CITIODy=5'working for me in B. El Remodeling • any capacity.[No workers'comp.insurance required.] • 9_ 11,1 Demolition 3-❑I lard.a homeowner doing all workmysdf[No workers'comp:insurance requirc..]t 10 r-lauildingaddition . ¢,❑I am a homeowner and will be hiring contractors to conduct all work on my property.I will Ll com ensationinsuranceDramsolo 11.ElElectricalrepairsoradditions ensure that all contractors cithcrhaYc workers' p • preprint-ors with noemployees.• - 1Z❑Plumbing repairs oradditions 5E]I am a general conbactorand I have hired the sub-contractors listed on the attached sheet 13 Roof repairs These sub-contractors have employees and hare-workers'comp.insurance? 14.DOther • 6.0w.are a corporation and its officers hive exercised their right afexemption perMGL o. 152,§1(4),and we have no cmployec [No works'romp.insurance Inquired-] *Any applicant that checks bozr'?l must also filloutthesectionbelowshowingtheirworkers'comprnsationpolicyinformaton. t Romrowncm who submit this atpdavitindicating they aro doing all work and then hire outside contractors must submit a now affidavit indicating such. tContr-actnrs that cheat this box must attached an additional sheet showing the name of the sub-contractors and state whether or not lhase entities have employees. Tithe sub-contractors hate employees,they must provide their workers'comp.policy number. . mmrrus employer Employer atirprovidngworkers• c.onrpensatianinsurrrncefornryemployees. 13eloit'is-tlrepolicymrdjobsite 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 MU.c.I52,§25A is a criminal violation punishable by afine up to$1,500.00 and/or one-year imprisonment a$well as civil penalties in the form of a STOP WORK ORDER_and a fine of up to$250.00 a . day ap in t the violator.A copy of thi c statement may be forwarded to the Office of Investigations of the DIA for ms>sance coverage verification_ ' I do hereby certi underthepeins turd perrnitirs ofperjrriy Olathe information provided above is true and correct. Signature_ Date: • ?harm#: ' • OffrrfRT use only_ Da not write in this m-ea,to be completed'by city or town official • City or Town: Permit/License# , Issuing Authority(circle one): • X Board of fean 2.BuildingDepalfiuent 3_City/Town Clerk 4.Electrical Inspector S.Plumb lug lnspector , 6_Other I' Phone#: Contact Person: