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HomeMy WebLinkAboutBLDG-21-004984 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '747•1111Mt CITY YARMOUTH MA DATE March 04,2021 PERMIT# BLDG 21-004984 JOBSITE ADDRESS 10 WHALE RD OWNER'S NAME WOJNAR THEODORE J JR G OWNER ADDRESS WOJNAR SUSAN 0 104 CALVI CT BELLAIRE TX 77401 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 1 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 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 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. PLUMBER-GASFITTER NAME Gary Famigliette LICENSE# 10191 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: GARY FAMIGLIETTE ADDRESS. 67 MAPLE AVE, CITY HYANNIS STATE MA ZIP 026014403 TEL FAX 1 CELL EMAIL 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 - (V . Cgrn'J-,. Y�._. ._ I MA DATE-:_73 c _1 PERMIT# CY-OG--1(-GU `r JOBSITE ADDRESS J O G(J I) 4 ' • f OWNER'S NAME 1 Up 3 (V c.i.f GOWNER ADDRESS 1TEL '--1FAX~ _ PRIN TR OCCUPANCY TYPE COMMERCIAL; EDUCATIONAL J RESIDENTIAL}, 1 CLEARLY NEW:J RENOVATION:J REPLACEMENT::NO PLANS SUBMITTED: YES 3 NO;X:1 APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I I_.._J ____1_J _ _ ._ _J J 1—I J`_1_J__ _J_1 BOOSTER I f r I r —J— —1 _I i._1_1__I . . I—1 CONVERSION BURNER I__J_J I 1 I__I ! __J_J I__J_J_J COOK STOVE _J 1 _J I_1-1�_J _1—J±LI_1_J . - (__1 DIRECT VENT HEATER ________J _I _ I__ I_J____J I__1 _1—1 I__I____J DRYER• 1___LJ —I J._ _—I i—_J __J . 1 ! I___II__I FIREPLACE I .. J I—J__I_I _ --I - I_____1I _-_I._J—J_I FRYOLATOR '___I____J_I.-J _I ______J i _,I—J_J—__J_J 44) FURNACE __I I-_J______I__!_ I- I I____Ii—_ I—.. _1 ._I___I qIGENERATOR 1 I 1I ----I____J___J_J_ _I___.J____J_1 GRILLE i .. 1 (__1—J I._ __J'_-J -J_J _J __J_1 ___J INFRARED HEATER ___J_1—_I _J I_� -.. I_I I__I —J—J _I,J____J LABORATORY COCKS I ; it MAKEUP AIR UNIT i I __._I__!_J _._1 J 1 !_____i ____I_ I__1 OVEN _ i_ 1 i _ I I __ _.-_,_.I__I._I __-__J _ i I__J. I___I I POOL HEATER I ���1_-._._.J_.J,_I_I..__J.__I_ 1____J_._..1_I_.J_____J___J ROOM/SPACE HEATER _.! I__J I i, i f__1 i 1 __1 i__.J._.--_.I I ROOF TOP UNIT ___,_I i I _J I 1 I _____J i___j I_J TEST I ' 1 1__.__.I�% i i i_ I I UNIT HEATER __! 1,J _� _l—__.J 1--I ; _ i---i_1UNVENTED ROOM HEATER J_,J f _� _i_ f 1.....____J ____J !____.ii__I I____J WATER HEATER —1 I . .. 1 (._-_j_,l _____I__.1__J i OTHER I�J ! I __J. i_1—J I ____J_J_____I I_____I _J_ ' • 1 ---I i ! I____!._-_______i _. _ _.._J ._._._.I�! _-__I-J'__J I i 4 I �I _-1..__._J I .� _I_r! I.._____.I I - _J -i I -- I I f__� I I I , __1-! _'-i t INSURANCE COVERAGE CI have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES A NO J I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY :Sr,( OTHER TYPE INDEMNITY J BOND I_i 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 II AGENT ._J 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 a ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compf nce II Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME• GL-,r 12 t' 6 1 t e„Ai I LICENSE#%u1 I'I SIGNATURE MP'$J MGF J JP U JGF',_1 LPGI _ CORPORATION .J#' PARTNER/SHIP ? I LLC _(#` COMPANY NAME: I'll(' 0 I ADDRESS 6 i 4--(1) u' CITY Pit. n it 5 J STATE,. .. .`ZIP �.- I TEL S&63-�7��.�-1 S 1. FAX �. - CELL: EMAIL r d �n :'� C'aa 1(�L' �'... - , . • •. . 0.4 • The Commonwealth of Massachusetts • Department of Industrial Accidents _ '1A. . , -- Office of Investigations 4. _ .i'.. : 600 Washington Street ,1 Boston, MA 02111 " . www.mass.gov/dia • • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers • . Applicant Information Please Print Legibly Name (Business/Organization/Individual): -,� F.-CA' .�M (a t -(:_ P 6. tf -• v..: v1 C.. " . Address: `' i(2 -7 Av c____ . .. •City/State/Zipe 1 Phone #: ;� _ 7 x x= , Are you an employer? Check the appropriate box: Type of project (required): • i. . I am a employer with 4. I am a general contractor and I • employees (full and/or part-time).* have hired the sub-contractors �• New construe ion �?.' I am a sble proprietor or partner- 1/4, listed on the attached sheet. 7. ; Remodeling ... ``-•' These sub-contractors have ship and have no employees 8. Demolition • workingfor me in anycapacity. employees and have workers' P tJ'• 9. Building addition . • [No workers' comp. insurance comp. insurance.$ b' 5. We are a corporation and its 10. Electrical repairs or additions required.]• _ _ 4 3. .any a homeowner doing all work officers have exercised their I I . Plumbing repairs or additions . . tnyself. [No workers' comp. right of exemption per MGL 12. Roof repairs • r �nsut-a�tce required.] t c. 152, §1(4), and we have no • •i • employees. [No workers' l3. Other _ _ . comp. insurance required.] . • • 4•Any- applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. t itorne wipers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. • .. tC imtr+ctors 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. !?elmv is the policy and job site infprmation. • Insurance Company Name: Policy # or Self-ins. Lic. #: Expiration ate: _— __ _ • .Job Site Address: City/State/ ip: + Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). . . i ailure.to smite coverage as required under Section 25A of MGL c. 152 can lead to the im josition 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. • t de hereby certify unde the pains and penalties of perjury that the information provided ,ov is true and correct. •I` . S1.gli411 t:c: A./7,-3'- Date: 3 ,c3V •L:,• . , . )401.1c. fi T__5 E.))-- -` -25 — b 3 A .r-�.� • Official nse only. Do not write in this area, to be completed by city or town official ` - • 4 . City or Town: Permit/License # , • Issuing Authority (circle one): . 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical lnsp ; tor 5. Plumbing Inspector '6. Other Contact Person: Phone #: 1 • •