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HomeMy WebLinkAboutBLDP&G-21-002928 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • CITY 'YARMOUTH I MA DATE 111/20/20 I PERMIT# BLDP-21-002928 <� JOBSITE ADDRESS 146 WILSON RD I OWNERS NAME IDAUPHINAIS AGNES M 7� OWNER ADDRESS IKEEFE LOIS M 200 DEAN ST NORWOOD,MA 02062-4783 I TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:CIPLANS SUBMITTED: YES❑ NO 0 FIXTURES"t 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/OIUSAND 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 I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: YES 0 NO 0 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ BOND❑ OWNERS 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. LICENSEI1B573 I SIGNATURE PLUMBERS NAME (Troy GilbertI MP JP El ❑# I I PARTNERSHIP ❑# I I LLC ❑#I © COMPANY NAME (COASTAL MECHANICAL I ADDRESS 121 L Fruean Ave CITY 'WAREHAM I STATE IMA I ZIP 1025711324 I TEL I FAX I 1 CELL I I EMAIL Ilisa@coastalphc.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT FEES$ PERMIT# PLAN REVIEW NOTES ,.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK q. ' e. ,_,_... CITY West Yarmouth I MA DATE 11/12/2020 PERMIT # .)-- Lb J. JOBSITE ADDRESS 146 Wilson Road 1 OWNER'S NAMErMary Martin POWNER ADDRESS [ arne , TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Li RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: 12 PLANS SUBMITTED: YES NOD FIXTURES -1 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1111illiigIIIIIIFJIiiilllliWIMili iiiiii WON omit iiiiiiiM um CROSS CONNECTION DEVICE imitim,liiii: M. illitail mil MUM_ DEDICATED SPECIAL WASTE SYSTEM 1— .. mom DEDICATED GAS/OIL/SAND SYSTEM 111111111101. i I DEDICATED GREASE SYSTEM 1 II I I DEDICATED GRAY WATER SYSTEMiinci ; DEDICATED WATER RECYCLE SYSTEM 1111111 ,#��� I I i DISHWASHER _ 1j1MIIIiP .111111 11111111111111111111111. DRINKING FOUNTAIN MJMMIMNMIN.MIM mi. inn WIWI , MN FOOD DISPOSER I1jI Ii '� I�■w■�'i ? , - FLOOR / AREA DRAIN I INTERCEPTOR (INTERIOR) mut_ i i , KITCHEN SINK LAVATORY J MI 1 ___ IIII. ' ROOF 011111M Mf IMIl '!�I SHOWER STALL 1111111101. Man M MOM SERVICE / MOP SINK IIIIIMI L TOILET ammmmIIIIIIIMM maimm FM1111111111.EllII�� I, URINAL I_JI r— NAME IN■I■II II 1 WASHING MACHINE C:ONNECTIONjIIIPMIIIM NM MI WATER HEATER ALL TYPES MIL_ j� iElii� Ilignilill!iiiiiill WATER PIPING I OTHER MEM=ramm Imo MINIIIIIIIIIIIIIIIIIIJIIIIimgummmrmna IIIIIIIINIIIIIIIIIMIIIIIIIIIIIIIIIIIIIIIUIIIIIM am �I�I I '_ ICI I INSURANCE COVERAGE: I have a current Iiabilinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES i NO F. IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSJRANCE POLICY i 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 i 3sued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /7 ,a /l�Q _ PLUMBER'S NAME Troy Gilbert__ LICENSE # 13573 SIGNATURE MPQ JP D CORPORATIONLOL PARTNERSHIPL „ # �.i ttC W��# 4350:.r.,,� I�..„ COMPANY NAMELCoastal Mechanical I ADDRESS { 21 L Fruean Ave "• ... CITY[South Yarmouth STATE MA ZIP 02664 TEL 508-7C74747C1 1 L 2122 FAX I —1 CELL 508-850-6955 EMAIL LlIsa@coastalkhc.com ---,..,. M _,. _.__ , ____.. ._u_________,_ Ri i u : 4 - .-4--�__ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK L �r CITY ["ARMOUTH MA DATE November 20, 202( PERMIT # BLDP-21 -002928 '.% JOBSITE ADDRESS 146 WILSON RD OWNER'S NAME DAUPHINAIS AGNES M G OWNER ADDRESS KEEFE LOIS M 200 DEAN ST NCRWOOD MA 02062-4783 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL Eli PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES LI NO 1=I —� 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 I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability ina rance 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 INSL RANCE POLICY LI 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 Troy Gilbert LICENSE # 13573 SIGNATURE MP [II MGF 1:1 JP LI JGF LI LPGI ❑ CORPORATION E:1 # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME: EOASTAL MECHANICAL ADDRESS. 21 L Fruean Ave, CITY WAREHAM STATE MA ZIP 025711324 TEL FAX CELL EMAIL lisa(a,coastalphc.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 i.i) - --$ r; k,,,,, CITY West Yarmouth MA DATE 11/12/2020 PERMIT # JOBSITE ADDRESS 46 Wilson Road �._.. a OWNER'S NAME Mary Martin GOWNER ADDRESS Save TEL FAX . I TYPE OR OCCUPANCY TYPE COMMERCIAL, I EDUCATIONAL RESIDENTIALLY PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: i PLANS SUBMITTED: YES NO( APPLIANCES -1 FLOORS—) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 ;;,I .i. - : BOILER I�...-..�. .Wy.... ... �...�..F. . _ . !.: ., w : ....� BOOSTER lr _ _.-� ... CONVERSION BURNER i r COOK STOVE 7sv . 'klr2 „....., DIRECT VENT HEATER DRYER � - -- FIREPLACE FRYOLATORL = .r FURNACE GENERATOR _. -_: �. ____._ ,..�. GRILLE INFRARED HEATER I _Li..j ,, .. la --Q . .. . LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ...id—N.-4 ROOM / SPACE HEATER ., . ROOF TOP UNIT I L, - ,... -.... TEST ,. 1 . UNIT HEATER UNVENTED ROOM HEATER __:—.E.........Li...... .., WATER HEATER _ 1 , . _.. � .-_ - OTHER , _ _-- . - . .....� _,. .�. _._ l� .� INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES � ' NO ! I I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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 L1 SIGNATURE OF OWNER OR AGENT I hereby certify that al 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. 7-w PLUMBER-GASFITTER NAME Troy Gilbert LICENSE # 13573 f IGNATURE MP i MGF JP ® JGF[j LPG'❑ CORPORATION D# ' PARTNERSHIP ,D#F - 1 LLC rj# 4350 COMPANY NAME: Coastal Mechanical ADDRESS 21L Fruean Ave CITY LSouth Yarmouth STATE [ MA—1 ZIPL02664 TEL 5 -R7- 47..- . ' , r) !I FAX 1 CELLL508-850-6955 EMAILLIisa coastal hc.com Ito 4- , • • ,Yam_`OMMONWF YLTH OF MAS 1 HUSET•TSS '•""« . DIVISION OF PROFESSIONAL LICENSURE • �,_' ,. FT`• �'Sb :<PLUMBEFR&AND GASFITT R % 40 ISS.J � FOL :.T ' LOWING11SE ..;R EMST RED.PL U IB1t4G COF .,^1' k; ,'. „TRQ'J GILBERT `t,; .. j``r, �t .�a -, �"i•COAST -- q' I t FL 4 qI.\f?; ,;NI tNG AND HEATI.i , 'T> 39 STATION�S�IF'REET: - y�,' .. cs.$',/ ,,,,;• '. F 2 i ? �,. i r :.i >WAR HAM,MA 02514 - 1'-. .4.'l -`''$ ),‘ , • ,.. 4350'e tau- 05/01 20,2 iz. ' .''''''' ... it... y.�,tM1 tz �•. ?'r�;y;: ..: 856115 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER t7) OMMO W TH OF M 646S 1.1. • DIVISION OF PROFESSIONAL;LICENSURE BOAQJ= , PLUMBER&S Nb GASF�TTEi r '"k" �.4: };� ISSUES'T: E FOLLOWING"I(CFi� <:- '. ' I ?a' il J>URN EY �+as- ¢'' a..,.�. Ply.� �s. • ` ..* j r 4YQ J GILBERT �,, Z „ 1 , 'S ATIONST 4 <'A 1 a _ WAREFAMMA 0257i1 a, ; , / xv14 . • 25383 ✓ ats 0g/0t/202 83'15'8 i • LICENSE NUMBER $ " ' ? • 1 EXPIRATlDN DATE SERIAL NUMBER / __ `� CONTROL#. J 014 6 2 7 8 4 coNTRoL ?�014 3 8 2 81 IMPORTANT IMPORTANT if your license is lost,damaged or destroyed;is inaccurate;or If your license Is lost,damaged or destroyed;Is inaccurate;or 111. needs to be corrected,visit our web site at mass.gov/dpl for of our Renewal needs to be corrected,visit our web site at mass.gov/dpi for instructions to ensure the proper mailing of your Renewal roper mailing y a instructions to ensure the p Application and any other correspondence. Application and any other•corresporidence• This license is subject to Massachusetts General taws and This license is subject to Massachu et a!lei ecanno bet nt or regulations.Your license r a privilege,and cannot be lent or regulations.Your license is a privlleg • nalty,of aw EeP this assigned to any person or entity under penalty of law.Keep this assignedtoanyperson or ensRy�uas reqed by law and/or license on your person or posted as required by law and/or license on your Person or Po • regulations. ! regulations. The Commonwealth of Massachusetts ► '�_ Department of Industrial Accidents _ 161 1 Congress Street,Suite 100 .w ��= Boston,MA 02114-2017 t>? wwwmass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Legibly Name (Business/Organixation/individual):Coastal Mechanical Address: 21 L Fruean Ave City/State/Zip:South Yarmouth, MA 02664 Phone#: 508-737-8747 Are you an employer?Check the appropriate box: Type I project(required): l.62ft sin a employer with employees(full and/or part-time).* 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. remodeling any capacity,[No workers'comp.insurance required.] g. El Demolition 3.0 l am a homeowner doing all work myself.[No workers'comp.insurance required.)t 10❑Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property, t will ensure that a11. lectrical repairs or additionsll contractors either have workers'compensation insurance or arc sole proprietors with no employees. 12. Plumbing repairs or additions 5.0 I airs a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.' 14.[ Other HvAC 6.0 We area corporation and its officers have exercised their right of exemption per MCL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing rill 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 ant an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and job site information. Insurance Company Name: AIM Mutual Policy#or Self-ins.Lic.#: WMZ80080074082020A Expiration Date: 01/04/2021 Job Site Address: 46 Wilson Road City/State/Zip. West Yarmouth, MA 02673 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 punishable 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 certify tender the pains and penalties of pedury that the information provided above is true and correct. Signature: 944E44, Date: 11/12/2020 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(circle one): I.Board of Health 2,Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ' Client#:764315 2COASTALPLI ACORD TM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS U I HOLDER.THIS S0 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT The Hilb Group of N.E.dba NAME: PHONE 508 775-1620 Dowling&O'Neil Insurance Agy (ELAN°,Ext): ((ac,No): 5087781218 P.O.Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC INSURER A:Evanston Insurance Company 35378 INSURED INSURER B:A.I.M.Mutual Insurance Company Coastal Plumbing&Heating LLC 33758 Dba Coastal Mechanical INSURER C:Safety Insurance Company 39454 299 Whites Path INSURER D: South Yarmouth,MA 02664 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 ADDL SUER POUCY TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDDNYYY) (MM/DDDY/YYXYPY) LIMITS A X COMMERCIAL GENERAL UABILITY MKLVIPBC000737 01/04/2020 01/04/2021 EACH OCCURRENCE p ��EE $1,000,000 CLAIMS-MADE X OCCUR PREEMISES(EaoNccr�nce) $100,000 X BI/PD Ded:5,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRO-T GENERAL AGGREGATE $2,000,000 POLICY XI JEC LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: C AUTOMOBILE LIABILITY 5906835 COMBINED SINGLE LIMIT $01/04/2020 01/04/2021 (Eaaccadent> $1,000,000 ANY AUTO BODILY INJURY(Per person) $ AUTO ONLY X SCHEDULED HIRED NON OWNED BODILY INJURY(Per accident) $ X AUTOS ONLY X AUTOS ONLY PROPERTY DAMAGE (Per accident)_ $ A UMBRELLA LIAR OCCUR MKLVI EUL102215 01/04/2020 01/04/2021 $ EACH OCCURRENCE $1,000,000 X EXCESS UAB X CLAIMS-MADE AGGREGATE $1,000,000 DED RE I ENTION$ B WORKERS COMPENSATION $ AND EMPLOYERS'L1A61LrfY YIN WMZ80080074082020A 31/04/2020 01/04/2021 X PER OR- OFFICER/MEMBER�EXC UDED ECUTIVE1 N I N/A E.L.EACH ACCIDENT (Mandatory in NH) 1 $1,000,000 If yes,describe under E.L DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICYUMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Town Hall THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 134 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I .w., of.,ts...,, ACORD 25 2015/03 ©1988-2015 ACORD CORPORATION.All rights reserved. ( ) 1 of I The ACORD name and logo are registered marks of ACORD #S251644/M251588 LS1