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HomeMy WebLinkAboutBLDP&G-23-006057 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 11/4 * (0 CITY YARMOUTH MA DATE 5/3/23 PERMIT# BLDP 23 006057 LF JOBSITE ADDRESS 1111 FREEBOARD LN OWNERS NAME HANLEY PETER M P OWNER ADDRESS HANLEY ELIZABETH A 55 CAMBRIDGE ST METHUEN,MA 01844 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ 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 CONNECTION 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY 0 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. PLUMBERS NAME Charles Stockdale LICENSE 2#526 SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME I HARLES L STOCKDALE ADDRESS 256 MAYFAIR RD 256 MAYFAIR RD CITY SOUTH DENNIS STATE MA —I ZIP 026602803 TEL FAX I —I CELL —1 EMAIL clsplumb@gmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ FEES$ PERMIT H PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK M ; CITY Yarmouth MA DATE 4/30/2023 PERMfT# JOBSITE ADDRESS 111 Freeboard Ln. OWNER'S NAME Hanley OWNER ADDRESS same TEL 978-807-3335 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO FIXTURES Z FLOOR 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY f ATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL _ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING OTHER 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 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. PLUMBERS NAME Charles Stockdale LICENSE# 24526 SIGNATURE MP JP CORPORATION # PARTNERSHIP # LLC # COMPANY NAME Charles Stockdale ADDRESS 256 Mayfair Rd. CITY S.Dennis STATE MA ZIP 02660 TEL 508-398-2843 FAX CELL 774-208-1613 EMAIL clsplumb@gmail.com — - _ ..._w.. 1 }JS3ow aiiiiSM t-Jq MS O7R n-1 s".:1s, " t 101 E1OJTA JggA ,W;'O ..i1!J 8TT32Ufi'").k,... 2A r , ,i. - ,1-.-' i .r ', --.'. ^> > _ r,:,!'".;.: a -Y-',-.14A9lDOC' j Ao nYT TI1pSKI c .: I i_�. 1 U,'IT t _ , at r..131_ 1 _. ._._. . ; ,," - .___I. _ _ ''"� YtAfiit,/0101,10440Ud f1320G>'G tl� 1 �_ _ A,t - '.7 1 3,:, 3,V 9 ; .. • , x , 1 � i4I I 1 I. 5,� la z. ?�;;! ! I. _. 1_ , , . ilf ,rn , a'1 V.,..%'1 1:. . , F.:,=5:3i!ti1.'e•i?r'6'1;)y'i ,ir, :JFt -'J1i*"!f{P1';:'17;:;ti?1 u(I 1 i W'l' 9 C'.J' 3TAlc;t.lrf '11A :H ";'i .:r', ic! 7:')AN2.•1O.1'40 31,t ! "A'' '' ' '! 1JOY i ;-i ,•_, ,.yi yii . ., . :1 .i,: -- _;._ _ -- 1 ij 1,4 'i:.,. i!. . 5:::740,1/ -i.):',P 1',!iv'if ,'2 11/PC ':r` ii''$.:Si; _ •:,'i 1 +;.. . ;4 •17..--fir;•,!t emtfiop;i\. :.;}1 IJ"1' . .6!1RY'f!_.i n.) l :;f62;'!RA,+ 1Y1 !vA P!t4WO :Y IVO'Mr N.:�3 ;1 T 3 �q, t>- '1 9 ') v. '4'71 'r' O '.f� °n, ),.' t i .._.'t ;yf a ., e C , J ,F1 El�fil 16111�(i�19 \ y f h. )y�1;1 S7 A 9f11 19 no ii'7Q Fri 'f••' 1 i fit i,',, .t L. _ti,31 : .!it, .Icp.,. c .,tii .-.�:. 1 a ;�i1 ,9) l3 D9 . s t t! •a,., S l•'_) r!lldfi i,Ko!r6 il,lfii nIb . _ .4' ,L! ,<,i . . . sJWz'i N.parr:•,.-6IA , 3-1 ^i .._._ 7.;', 3-: '. . .V. ...11c' a141::-.11 2 39VIE.i_:'q ! . # ;!.1.1 ci t_l:.,51 '/4-7-7,-.f4 :, .. ;,,.:, apt I .1. -4,4 1. '1x i,i„4"i+.1? rGi,. "l i„ 6.44.0('i_,.) ' T �p DATE(MMIDD/YYYlr7 �►��o CERTIFICATE OF LIABILITY INSURANCE 04/12/2023 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 CONTANAME:CT Marshall K. Lovelette Marshall K Lovelette Insurance Agency Inc PHONE FAX 396 Main St (A/C.No.Ext): (508) 775-4559 (A/C,No): E-MAIL marshall@loveletteins.com West Yamouth, MA 02673 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Safety Insurance Company 0005 INSURED Charles Stockdale DBA CLS Plumbing INSURER B: 256 MayFair Road INSURER C: South Dennis, MA 02660 INSURER D: INSURER E: 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. INSR INSDA WVD TYPE OF INSURANCE SUER POLICY EFF POLICY EXP LTR POLICY NUMBER (MM/DD/YYYY) (MM/ IDDIYYYY) LIMITS A ✓ I COMMERCIAL GENERAL UABIUTY BMA0028545 02/13/2023 02/13/2024 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE I OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- CT LOC PRODUCTS-COMP/OP AGG $ 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) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ _ DED RETENTION$ _ $ WORKERS COMPENSATION STATUTE PER OTT AND EMPLOYERS'LIABILITY Y/N ER ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below , E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rt 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE I K1'174-441 4-4:7'.--;4:3 99" ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE May 03,2023 PERMIT# BLDP-23-006057 JOBSITE ADDRESS 111 FREEBOARD LN OWNER'S NAME HANLEY PETER M G OWNER ADDRESS HANLEY ELIZABETH A 55 CAMBRIDGE ST METHUEN MA 01844 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El 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 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 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 El 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 ❑ 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 Charles Stockdale LICENSE# 24526 SIGNATURE MP 0 MGF 0 JP El JGF❑ LPG! 0 CORPORATION❑# PARTNERSHIP ❑#r LLC❑# COMPANY NAME: CHARLES L STOCKDALE ADDRESS. 256 MAYFAIR RD,256 MAYFAIR RD CITY ISOUTH DENNIS ISTATE MA ZIP 026602803 TEL FAX CELL EMAIL clsplumbWgmail.com 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Yarmouth MA DATE 4/30/2023 PERJ1 P6- 3 -'d6 737 JOBSITE ADDRESS 111 Freeboard Ln. OWNER'S NAME Hanley GOWNER ADDRESS same TEL 978-807-3335 FAX TYPE PRINT OR 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 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER t" `" ROOF TOP UNITTEST U 2023 UNIT HEATER MAY UWATER NVTED ROOM HEATER t E3U1 p £ 1 M OTHER 6y INSURANCE COVERAGE 1 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 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 Stale Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Charles Stockdale LICENSE# 24526 SIGNATURE MP MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC # COMPANY NAME: Charles Stockdale ADDRESS 256 Mayfair Rd. CITY S.Dennis STATE MA ZIP 02660 TEL 508-398-2843 FAX CELL 774-208-1613 EMAIL clsplumb@gmail.com -—---- __, 1 — f ? IOW 01411111 2A0 MAOR5713c1 OT T;!)1;•; 't; A SInti 001TAOLIcicA MHO:WU :17-1.3eUHOA28APA .....:. • -'?..:i- "'._ • 1 " ''';':>1 T:4 :',....s:::,:,,, i, •:!,.., ' -10 dtWf Y i 13 • c.- --: ; ' ; . . . I •1411KL! 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