HomeMy WebLinkAboutBLDG-25-688 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY:://91/l l 11 f bf t MA.A DATE: PERMIT# 6—23—fb4"
JOBSITE ADDRESS: h a Li), l 1 QUJ ,S I OWNER'S NAME:
GOWNER ADDRESS: TEL: FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL*
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENTS PLANS SUBMITTED:YES 0 NO 91
APPLIANCES? FLOOR—. Bsmt 1 2 3 4 6 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR 7175
FURNACE
GENERATOR
GRILLE
1%t INFRARED HEATER
W LABORATORY COCK
MAKEUP AIR UNIT
' OVEN
POOL HEATER
ROOM/SPACE HEATER
J ROOF TOP UNIT
TEST J
UNIT HEATER
'L 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 Yf"'NO 0
If you have checked YES,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 Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this app§cation are true and accurst ale best of my
Knowledge and that all plumbing work and installations performed under the permit Issued for lids application wll a In tnpl c WIth all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFITTEERNA;MME::/DrHP Zr)S5i IG LICENSE#3�q7� TURE
IJ t 1 COMPANY NAME:L� Pf J✓11�iY t"kcrl ADDRESS:
CITY: tiff' VI( STAT. MA ZIP: FAX
TEL: CELL: S 05'77615? y3 EMAIL: ,Ari�0 ,SS�I /ar Ariy4a 1 (CPI)
MASTER❑ JOURNEYMAN k LP INSTALLER❑ CORPORATION❑# PARTNERSHIP(❑# LLC❑#
c h7/3 L ADD2e 5S
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMITI
PLAN REVIEW NOTES
I5A7F(hiNlnn(YYYY}
ACt7RLP CERTIFICATE OF LIABILITY INSURANCE
, ,r 09 28f2023
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND,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 poilcy(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 IieII of such endorsement(s)-
PhoduClrR di5 iTAC1 Glen Davis
, NAME:
"f he Hiib Group New England,LLCoNE (800)640-1620 FAX
-Yt1f Ir'Extl (A7C No:
dba Dowling&O'Neil ADDRESS: gduvi (g)hilbgraup.com
973 Iyannough Road INSURER(S)AFFORDING COVERAGE NAIL II
I tyannis MA 021301 INsuRER A: MAPFRE Insurance Company 23876
INSURED INSURER 8
Lbj Plumbing and Heating LLC INSURER C:
.
t34 Bog Ln INSURER o: -- ,..,-..- .n-�.�, __._._.....,_.o.,�._......:_:,
INSURER E:
Harwich MA 02645 INSURER F
COVERAGES CERTIFICATE NUMBER: C123928204 s7 REVISION NUMBER:.
THIS IS 'CO C--R"f IF "TI4AT'THF.POI.CCii S Of INSUi2.ANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NO Mil HSTANDING 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 RFFN REDUCED BY PAID CI AIMS.
INSR ADML'SUBR T POLICY Or POLICY 3(P _ - .
1.TR TYPE OF INSURANCE MSC WVD POLICY NUMBER INM MI lDofYYYY)l(MDDIYYYII. — LIMITS
X COMMERCIAL.GENERAL L/ARILITV ^.•. . EACH OCCURRENCE I 1,000,000
._
DAMAGC'rE)RENTED 1 OU,00U
MAIMS-MADE [ OCCUR PREMISES f Eia ocourren00) . i
MED JEP t one Person) 4$ `�.t)01) .--- -,
A 8008030007417 08/17/2023 08/1772024 PERSONAL&ADV INJURY $ _
G€N'L AGGREGATE LIMIT APPLIES PER, GENERAL AGGREGATE $ 2.0Cif),000
POLICY Li IE¢ 0 LOC PRODUCTS L:OMP/OP AGO $ 1.,t300,OR0
>
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT t
(Fri RCt c1Lf )
ANY AUTO) BODILY INJURY(Per Larson a $
OWNED — SCHEDULED BODILY INJURY(Per act-dent) $ .
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
,,, AUTOS ONLY F AUTOS ONLY (Per ru4 ernri_._.
-
UMBRELLA LIAB OCCURI EACH OCCURRENCE $
—
EXCESS LIAR CLAIMS-MADE AGGREGATE $
1)FE) RETENTIONS $
r_ WORKERS COMPENSATION PER 0TH-
AND EMPLOYERS'LIABILITY Y t N STATUTE [R .---.
ANY PROPMEToR'PARTNrR,EXECUTIVE. N 1 A EL EACH ACCIDENT $
OFFICE':R/maimm-R EXCLUDED?.
'(Mandatory In HN) El.DISEASE-EA EMPLOYEE 1$
If PCs,tJt;':i(nbe Lode(
DE.SCRIPTION OF OPERATIONS beiew E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES IACORD 1o1,Additional Remarks Schedule,may be atte hed if mute apace 6 reyuared)
Insurance coverage is limited to the terms,conditions.exclusions,other limitations,and endorsements.Nothing contained in the Certificate o:insurance
shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions
C[RTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
T. ,,of Urteans ACCORDANCE WITH THE POLICY PROVISIONS.
19 School Road
AUTHORIZED REPRESENTATIVE
()deans MA 02653 ,._! ,,,.
q: 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(201 )103) The ACORD name and logo are registered marks of ACORD
# COMMON . IF a: _A N . 1
DIVISION OF OCCUPATIONAL L.JCENSURE
BOARD OF
PLUMBERS AND.GASFITTERS
ISSUES THE FOLLOWING LICENSE
JOURNEYMAN PLUMBER
LORNE B JUSSILA
84 BOG LANE
HARIA!ICH,MA 02645
31971 0.5101)2026 573757
NLIAU R EXPIRATION DATE� NUMBER