Loading...
HomeMy WebLinkAboutBLDG-21-000275 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •• r` CITY !YARMOUTH I MA DATE ruly 20,2020 (PERMIT# BLDG-21-000275 JOBSITE ADDRESS 36 WEST WOODS VILLAGE OWNER'S NAME IHARLIN JOHN G OWNER ADDRESS BOX 11 HYANNIS MA 02601 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES 0 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 1 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 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 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 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 David Houde LICENSE# 16673 II SIGNATURE MP©MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION 0# ,J PARTNERSHIP ❑# LLC 0# COMPANY NAME: DA'✓ID HOUDE DBA HOUDE PLUMBING I ADDRESS. 1016 Queen Anne Road, CITY 'Harwich I STATE Ma ZIP 02645 TEL FAX CELL EMAIL davidhoude6(a)gmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El ❑ FEE: $ PERMIT# PLAN REVIEW NOTES :) — �3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '''"= Yarmouth Port MA DATE 7/14/20 PERMIT# L6 - eV;7S =, CITY JOBSITE ADDRESS 36 West Woods Village OWNER'S NAME John Harlin GOWNER ADDRESS 36 West Woods, Yarmouth Port, MA 0267-L 508-362-6300 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO APPLIANCES 1 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 1 FRYOLATOR FURNACE X GENERATOR GRILLE INFRARED HEATER }," LABORATORY COCKS i `c C ,.. 1 j `• • MAKEUP AIR UNIT OVEN I JUL �.U Ala POOL HEATER ROOM I SPACE HEATER j ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I 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 compe with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. —/,1J PLUMBER-GASFITTER NAME David D Houde LICENSE# 16673 SIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION®# 4333 PARTNERSHIP❑# LLC❑# COMPANY NAME McDonnell Mechanical Services, Inc ADDRESS 79 School Street CITY W Dennis STATE MA ZIP 02670 TEL 508-394-0005 FAX 508-394-5050 CELL 508-246-3152 EMAIL barbara@mcdonnellmechanical.com Fold, Then Detach Along All Perforations A_ COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED PLUMBING CORP C DAVID D HOUDE MCDONNELL. MECHANICAL SERVICES, INC. Lulls 79 SCHOOL STREET W. DENNIS, MA 02670 4333 05/01/2022 812241 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER ACORO® DATE(MMIDDIYrnq CERTIFICATE OF LIABILITY INSURANCE 06/25/2020 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 N CAMEONTACT Nancy Souk,CISR Dowling E.O'Neil Insurance Agency ' �I: (800)640-1620 I NO 973 lyannough Road E-MAIL fSWIR@dOInS.COn INSURERS)AFFORDING COVERAGE NAIC II Hyannis MA 02601 IRslamnA: Tri-State Insurance Co.of Minnesota 31003 INSURED WSIIRERa: Acadia Insurance Company 31325 McDonnell Mechanical Services,Inc. INsURERc: Twin City Fire Insurance Company 29459 79 School Street INSURER D: INSURER E: West Dennis MA 02670-2445 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 WA p WV LIR POLICY NUMBER NAIND,,YYVY) (MWDD(YYTY) LIMITS X COMMERCIAL GENERALUABIIJTY EACH OCCURRENCE f 1,000,000 DAMAGE TU HEN I ED CLAIMS-MADE ®OCCUR PREMISES(Ea occurrence) $300,000 MED EXP(Any k perm) $10,000 we A ADV0395010-19 05/19/2020 05/19/2021 PERSONAL dADV INJURY f 1,000,000 GEN'L AGGREGATE OMIT APPLIES PER: GENERAL AGGREGATE f 2.000,000 POLICY®J�D-CT ®LOC PRODUCTS-COMP/OP AGG $2,000,000 S OTHER' 'COMBINED SINGLE UMIT AUTOMOBNE LIABILITY COMBINED accident) $1,000,000 ANY AUTO BODILY INJURY(Per person) $ B `OWNED X SCHEDULED A0A0395008-20 05/19/2020 05/19/2021 BODILY INJURY(Per eroden) f AUTOS ONLYAMOS X PROPERTY DAMAGE HIRED X NOS`D (Per accident) S AUTOS ONLY S X UMBRELLA LIAR X OCCUR EACH OCCURRENCE f 2,000,000 — B EXCESS LIAR — CUVMSMADE CUA5250858-14 05/19/2020 05/19/2021 AGGREGATE f 2,000,000 DED I XI RETENTION E 0 ��I E IO WORKERS COMPENSATION /�I S ATUTE I I ER AND EMPLOYERS'LIABILITY C ANY PROPRIETOR/PARTNER/EXECUTIVE Y� NIA 08WECCF1837 0&OB/2020 OS/OBT2021 E.L EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? 500,000 Iatmlotory In NH) E.L DISEASE-EA EMPLOYEE S 1 yea,describe under 500,000 DESCRIPTION OF OPERATIONS bear( E.L DISEASE-POLICY UMIT E DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD t01,Additional Remark*Schedule,nay be attached I mon apace 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 McDonnell Mechanical Services,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 79 School Street AUTHORIZED REPRESENTATIVE /` West Dennis MA 02670 --✓:���., � I ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD