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HomeMy WebLinkAboutBLDG-25-533 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY: 1PAW°Vii4 MA DATE:9Ji i.-2L-5 PERMITII ZS533 JOBSITE ADDRESS: I C ( t N t me') K I> OWNER'S NAME:CA GOWNER ADDRESS: TEL: S0. 7n4' 1I2 )FAX: TYPE Oft OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL . PROT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: , PLANS SUBMITTED:YES❑ NOIr APPLIANCES? FLOOR-. Bamt 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 CA INFRARED HEATER LABORATORY COCK _ �v MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER -) ROOF TOP UNIT fi TEST I SEP 3 02025 UNIT HEATER t,U UNVENTED ROOM HEATER WATER HEATER 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 have checked nF,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER gi AGENT 0 SIGNATURE WN GENT hereby certify that all of the details and information I have submitted(or entered)regarding this epptcation are true and accurate to the best of my Knowledge and that all plumbing work end installations performed under the permit Issued for tits application oft camps wI h ertinent provision of the Massachusetts State Plumbing Code and GAS Chapter 142of the General Laws.n i PLUMBER/ FITTER NAME: I� - te� C.EN f c 41 LICENSE it (7 I;II NATURE COMPANY NAME::WJ(S T 1144CG4- ( 11 ADDRESS: L r A 7'4 CITY:S r \/M fl1OU t-f l( STATE: V 11r1 ZIP: 0'21126714- FAX: TEL: 5CK "'311 " 1 CELL: EMAIL: KecicteD 60A,s4Airlic LCWI MASTER JOURNEYMAN❑ LP INSTALLER❑ CORPORATION 0# PARTNERSHIP❑k LLC®k it35O E/7/JiL. WZ zeSS: The Commonwealth of Massachusetts Department of Industrial Accidents -•r 1 7 Office of Investigations I'. Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Coastal Mechanical Address:22 Whites Path City/State/Zip:South Yarmouth, MA 02664 Phone #:508-737-8747 Are you an employer? Check the appropriate box: Type of project(required): 1.0 1 am a employer with 40 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. El New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P h'. 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152. §1(4),and we have no GAS TEST employees. [No workers' I3.® Other comp. insurance required.] "Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors 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: Hartford Underwriters Insurance Company Policy#or Self-ins. Lic. #:08WECBC2X9T Expiration Date: 12/31/2024 Job Site Address: 10 MONOMOY ROAD City/State/Zip; SOUTH YARMOUTH 02664 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: 46 Date: 09/30/25 Phone#: 508-737-8747 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10 Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5EIPlumbing Inspector 6.DOther Contact Person: Phone#: ® AcoRta CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) r---, 12/30/2024 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 CONTACT Tina Reeves NAME: The Hilb Group New England, LLC PHONE (800) 640-1620 FAX {{A/C,No,Extl: (A/C,No): dba Dowling & O'Neil E-MAIL SS: treeves@hilbgroup.com 973 lyannough Road INSURER(S)AFFORDING COVERAGE NAIC Hyannis MA 02601 INSURER A: Property & Casualty Insurance Co of Hartford 34690 INSURED INSURER B : Arbella Protection Insurance Co 41360 Coastal Plumbing & Heating LLC INSURER C : Hartford Underwriters Insurance Co 30104 22 Whites Path INSURER D : Westchester Surplus Lines Ins 10172 INSURER E : South Yarmouth MA 026E4-1212 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 TYPE OF INSURANCE ADDZSU$R POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DO/YYYY) (MMFDD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE •X1 OCCUR PREMISES Ea occurrence) $ 1,000,000 MED EXP(Any one person) v $ 10,000 A 08SBABL9L1S 12/31/2024 12/31/2025 PERSONAL&ADV INJURY $ 1,000,000 — GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ ,000,000 PRO- 2,000.000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED X SCHEDULED 1020153682 12/31/2024 12/31/2025 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X AUTOS ONLY AUTOS ONLY (Per accident) $ I X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000.000 A EXCESS UAB CLAIMS-MADE 08SBABL9L1 S 12/31/2024 12/31/2025 AGGREGATE $ 2,000,000 1 DED XI RETENTION $ 10,000 $ WORKERS COMPENSATION X PER H STATUTE ER AND EMPLOYERS'LIABILITY Y IN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 C OFFICER/MEMBER EXCLUDED'? N N/A 08WECBC2X9T 12/31/2024 12/31/2025 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1'000,000 If yes.describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE-POLICY LIMIT $ POLLUTION LIABILITY EACH POL CONDITION $500,000 D G74289587003 08/25/2024 08/25/2025 AGGREGATE $500,000 DEDUCTIBLE $2,500 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms, conditions, exclusions, other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered, waived, or extended thecoverage provided by the policy provisions. 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 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 r"� - I = --J — r- © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD