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Home My WebLink AboutBLDG-21-001552 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t;, a CITY EARMOUTH MA DATE September 25,202 PERMIT# BLDG-21-001552 JOBSITE ADDRESS 29 COTTAGE DR I OWNER'S NAME LAWLESS ROSALIE P G OWNER ADDRESS 118 MENDON ROAD SUTTON MA 01590 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 DRYER FIREPLACE FRYOLATOR FURNACE 1 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 Andrew Robert Leighton LICENSE# 3734 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION El# 3734 PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Hall Oil Company Inc ADDRESS. 435 ROUTE 134, CITY SOUTH DENNIS STATE MA ZIP 026735706 TEL FAX 1 CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - . CITY y,q/Z/Y000TJ-4 MA DATE�y70 PERMIT# BLbG-aI-COIS5 JOBSITEADDRESS G,?5/ Cb'0965e-Pi", OWNER'S NAME h-39Cie/ive " ofL?n.c5, G OWNER ADDRESS 29 /A. TEL,954g/6-e93-44 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL✓ PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED:YES NO✓ APPLIANCES 1 FLOORS BSM 1 2 1 3 4 5 6 I 7 18 9 10 11 1 12 13 14 BOILER • I . BOOSTER CONVERSION BURNER I COOK STOVE DIRECT VENT HEATER • DRYER - FIREPLACE FRYOLATOR I..... . - . . FURNACE 1 GENERATOR - . GRILLE _ INFRARED HEATER _ _ __ LABORATORY COCKS --- - MAKEUP AIR UNIT �A' OVEN - .. POOL HEATER - ROOM/SPACE HEATER . SE.P 18 2220 ROOF TOP UNIT TEST - _ _ .I I R i i i— ,i - - UNIT HEATER - _''y UNVENTED ROOM HEATER _ WATER HEATER • - OTHER INSURANCE COVERAGE // I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES t✓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 D 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 and t he b of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in plian II P rti 'ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i 1 PLUMBER-GASFITTER NAME ANDREW LEIGHTON LICENSE#16130-M SIGNATURE MP • MGF JP JGF LPGI CORPORATION # 3734C PARTNERSHIP # LLC # COMPANY NAME:HALL OIL COMPANY INC. ADDRESS 435 RT 134 CITY SOUTH DENNIS STATE MA ZIP 02860 TEL 508 398 3831 FAX 508-394-3068 CELL EMAIL halloilcompany@gmaiicom I The Commonwealth of Massachusetts u _ Department of Industrial Accidents ,.�*t Office of Investigations _ mu: y 600 Washington Street Boston, MA 02111 ;�.,3 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organi7ation/Individual): AV%AI C (C CC), 4—/LPe Address: -5122 -5 /?l e /3 V City/State/Zip: S o . Dey'vr1 t s HA Phone#: S07- 3 -3.Z? Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with /$ 4. I am a general contractor and I 6. New construction 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. Remodeling ship and have no employees These sub-contractors have 8. Demolition workingfor me in anycapacity. employees and have workers' P tY• 9. Building addition [No workers' comp. insurance comp. insurance.: required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their dr 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. 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: /t-/j} 1219 fj.l_ ci?2,f-TA 1.50 P R/V C6 '7CUU/, .C/IPC Policy#or Self-ins.Lic.#: D ?/O 0 ei//90 /9 2 / ?0 Expiration Date: //j.2/ Job Site Address: X 9 ( 2 of —T3". ;,A/r'ii . City/State/Zip:_ __ r 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 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u der the pains�annd�penalties� of perjury that the information provided above is true and correct. Sinnature: ,� �., 7 Date: �� .d Phone#: 20 `.39 — 3 `0.3 l 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 I Contact Person: Phone#: • Workers Compensation and Employers Liability insurance Policy Insurer ID No(s): 34363 Carrier Policy#: Policy Period II MA Trade -Insurance Group Inc. 021004100192120 01/01/2020 to 01/01/2021 PO Boxox859222-9222 Braintree, MA 02185-0000 Renewal Policy Information Page FEIN: 042149852 Carrier Prior Policy#: Agency Item 1: Named Insured and Address }Rogers i Gray Insurance Agency, Inc. Hall Oil Company Inc. 434 Route 134 P.O. Box South Dennis,MA 02660 South Dennis,is MA 02660 Other Workplaces Not Shown Above: See Schedule of Operations Additional Named Insured: See Additional Named Insureds if Applicable Federal ID#: 042149852 Type of Business: Corporation NCCI I Bureau#: 34363 Risk ID: 000048146 Unemployment ID#: File#: 021 0041 001 921 20 Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2020 to 12:01AM on 01/01/2021 based on the insured's mailing address time zone. Item 3.Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA B. Employers Liability insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $1,000,000.00 each accident Bodily Injury by Disease $1,000,000.00 policy limit Bodily Injury by Disease $1,000,000.00 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15),WC000313(04/84),WC000406(/),WC000414A(01/19),WC000422B(01/15), NOE(01/01),WC200102(01/14), WC200301(04/84),WC200302A(09/08),WC200303D(08/10),WC200306B(06/13),WC200405(06/01),WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration I See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit $536.00 $ 15,900.00 $ 15,900.00 $0.00 $0.00 Q� ��/ issuing Office: Braintree Hill Offi Park Ste 206 Date Printed: Countersigned by: 12-18-2019 gl^)ce \-d �L7 Braintree MA 02185-0000 Form#WC 00 00 01 C (Ed.) Pant? i n; m Copyright 2013 Natiana Council on Compensation Insurance,Inc.All Rights Reserved.