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HomeMy WebLinkAboutBLDG-21-003740 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r ; CITY YARMOUTH MA DATE January 06,2021 PERMIT# BLDG-21-003740 J JOBSITE ADDRESS 181 SILVER LEAF LN OWNERS NAME SPURR GARY A G OWNER ADDRESS 181 SILVER LEAF LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO 0 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 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 ❑ 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 ❑ 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 Spencer Hallett LICENSE# 16224 SIGNATURE MP© MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: SPENCER HALLETT ADDRESS. 381 Old Falmouth Rd Unit 36, CITY MARSTONS MLS STATE MA ZIP 1026481372 I TEL I FAX CELL 1 1 EMAIL Ispencer(a)hallettplumbinq.com S310N M3IA38 NVId #11I Rd $.33d ❑ ❑ iII l 3d 3H1 SV S3A213S NOI LVOIlddV SIHl oN so), S310N N01103dSNI IVNId AINO 3Sfl NO103dSNI a0d 3OVd SIHl S310N N01103dSNI SVO HOfl0a WIASSACHUSE'r at S UNIFORM APPLICATION! FOR A PERMIT TO PERFORM GAS EHITING WORK) _......... CITY _�y:a:r:m:::oL"u:tyi::.„ - :, _�_:_ �.1 NIA DATE[1:1::...21:24C-111"2-{.1.9:29-11PERMIT#BW —li—7.::::- , . r. .-..,.-,_ -..rn.s ..a., JOBSITE ADDRESS ::::,f_871,,_Tr.ffyi-ri-Loir,t,ca.„.--iyp::::::.----..---,,,..Lane OWNER�s NAME Spurr'rnY ����' n,aar..� `___,��\ f-C a.„.-_4.,.,p:::::•3_ti-..-it: 1tfi, ^. y T' 3 ti `' OWNER ADDRESS C-~181- SilverT�ea �ane� �.__�, TE�I�_�� FAX ,_•.�.,.www� \,:.--..�.. . i .�....✓-._w... ..^4: •..-�flv�.{t..P%w•.{'.:---p\Z :YSiYt„...,„_•Y..J._.. F/V\�„: j •__.-- _•' - �15-i,�:__�'•3.f:s\,GiLCC�i..�U.4\G:f3^� i••{ TPRINTYPE Oft OCCUPANCY TYPE GOMMERGIAL(�.� EDUCATIONAL .,. RESIDENTIAL1. CLEARLY NEW 177 RENOVATION: REPLACEMENT: :,_, PLANS SUBMITTED: YES NOL s APPLIANCES 1 FLOORS--► BSM 1 2 3 5 6 7 8 9 10 11 12 13 14 , BOILER ?_.._-.:.L • �� I_,.,.�.^.. r--__ ▪_,T,; .-_: =s!..• � I.�Y•V.4.T�_....-.:.:��C�z:._.�_.: ::-:.:,. • ::r.�:.T:L=.•t:; t. I r BOOSTER ,I.-.7_,,,..... ;r I ."?�- -�� - = T.•__JI.,,.,..., ,r_ I!.._ .... (W4�1-�i L_▪ : .1jy� ! CONVERSION BURN1- �' '--- 1- -4;^ --. 1 1--tom: ,.._ ---_- COOK STOVE —_=, W �__- --- , °� v.-__; _ __ �:. __ _ -; z_ = - -,:r .. ��.:•..: t. . DIRECT VENT HEATER I-- _ �., �>*..u,- ...—...,„:,,-- _.� W .,:�L,�� .._.:.,. 11=--i 1-:_._. _-` ` fi n.r_.� �� �, . __ _ :f�:,..:...,�is-IF�:.�.,_-... .., DRYER I fi .I .. ._ _ „_T.:..:: ,•.._. ,__ ' -�-�. ,:,_ _ I_.- _._. ..-..:�1 ,,.-.N .✓ , I: -,._a _ _.._.r.a-. i..ac.N �i.-• __—�-1 I ..-�:�-,,-,I 1,:- Ty4,i la_:r.:�`-1 _ i 1 • �I FIREPLACE � I l rI r ., _ i z __::�a . _�I.. C�._.. .,. .-�., ...z-1:i�`....:�,•, . �_ �4 ,:•,•'I-= `:i.i-..r,:r:-.•an._,.r�) +=.�� ._t - ...� .-,ra.•` ...•. ,.il...., _� �,.-:.�di�..,.;._ ; i F,^RYOLA70R _ 1� YTS ��- —. _�1 11r ., ._.. �4 - i 1It—_ J1 — ] -_ �.��- •- ~_i ..,..a....h:t:- >. �.r.,Y,1- --.•C 1,4'_., ,,, _.T.-� --i l,,y,,:i� r-.-:•w `[-,^.,: - .S I.`v F._41'.,;y,:_��-,] �` 1 ' FURNACE 1".. I V_ i I``��i ..I I = ..t I�--- ; _____,C_:_� _ C: :_... /�- _ �;: ,. - t-�` .;.:y.t.,.. .-.�•-N.t.��.- ^,T t�,�-.... a ',.•: ..j .,V.�-. :. 1 GENERATOR _.._.�3 _ - -_.t :�t..,•,-:--1 T„_rt...4��_..,��{E,.:�n.-,_.�I::._,.v„1 .,,._a..1 __... . :,yam GRILLE I - . =•• ..._. ,� ----11 F,..:,;.,..,�_=I_;,,-a,1_,.1 I.-� if _. _-w -. I...,-.,:�1` i _ 1 I _� ..� ' `1 INFRARED HEATER — _�s. �� r�,, . _.�_ ___ __ =1,_. _ - - • fit r 2.,: __l _ _ LABORATORY COCKS 1"--, ,_ ._.i , ', -__t_ _�r��. �_ _IF if �^ ▪ _ rl —_ s/ r. MAKEUP AIR UNIT 3 ii -= - - w ii OVEN 11 POOL.HEATER - ,:_.�__.�.}I. �.. — -.__ :,---�=.t. .�� _ � ��1 x>> -._..... Y ._.i_.,�._z rn� »r_! ,.....-._.t _,vr-.:f,L.. F' St=_.....� ..,-' I•'••-._.r.`.,.- - .1--�:.. ,i _,i• �1_.i r ..:. • T. ROOM SPACE -_.� �.:,_�.: _.;__,_�-.;_ _ -- __ ,,,,.__:-�_ . _,.�, _..,.__...,.., M/ HEATER ._. I._ 4 _ � �, �i .._ -� }i =• � :�.,__F,. _ .�.:.�.� ROOF TOP UNIT • - - , _ .�..>,I_s�__--_3_ -._, _ _, €_^_ ,:C.v _�I.� ;— (_,. :_= _ . „; -...._,.€ ., :,��1�_ - :-�1,,••.-_ .Y? •I ..r.,::,�.,,;f,•..•_�,•.,,,1 f:.%..��. ..51y .u,-.-.j 1`,....,.-.o.i L.�..••',1 I-<..-:_...'I.T_ ei, ▪ - TEST �__:,. ---, -- — - , --- -: I�- • i i s j 1.__ _11:, =1 lr.- ,__� _, ��saw .__N_ - _ L� I.-..,....._ . f_ - , ;�..Y 1 �`, T' r' �.i[r�-._.. UNIT HEATER i _,r -- ..• - -..,.., ___.. -�1.,...___, _ _ uivvEHEATER �-ems ._ _.. .,��..i Imo._ _.)C...,�_,:-r1 : . _ :I_._.._�.,.�{I. ..a .-- -`__ ` NTEp ROOM li _� ,. .y.tii _ f �� .- ��.,.�_. C.,...�a,I. Y�_ I.�..�.,,N! 1 WATER HEATER ::—=�I =1i L... :,��I nz`~. _., ,,: _:-,-_- ::�_:!•- ..........3 I:.��_ - '_ f•.,_ _ _r ;! -�i ..�. OTHER _�� ,��_.�- __� _ �. :�:�}I. ��:.._ �.._ if II �-s I w. t ,-�._ ' 1 j ry 1 �� [,.•._ \I ,L :I. . rr."`l t. -i 1. 3 I _ :•, s .,..,::I. s y L,'_._._.�_. ...,. is1v t __—: ���,..:_._� 46.,w.:.. g. � =:: ��,,}= L., - �.j i�.�r.CT� ..i I. I I...,._..__.�1r.: - L.,-:.__.1 I:-..ti,.�. :,_;(.-_: :..,C. __,_,...--.4 lr,..erus ,‘L.-..l.,...4.,,,,-......,-..., S. ii -r-:.�i:r'/.ant,:,.Y:�ti--....�,:.r__.._,_-_.rl.__..:J.:G:`_sl:-}_-_� :,y {r2S.y1:lJ.1b :•: .I,,:L...�.,.. .▪ -,Y '.1 w.....Ic _ vi t~ _ _ ( T i l Cis A.44 is 0 t�s ,s .. ,�:ti �: -�f ._J�. .�7`vim ma: :r.� .r:a, :1._r- -•`t •::,tn.z .E l =,C{��.rr,. �' I ! - '1 ,.., .I_ _r�- ` 1 1 it ,.:aJ�:T, .Y T I l ~ INSURANCE COVERAGEii I have a current liability insurance policy or its substantial equivalent which mats the requirements of M L° - - 1 r I IP YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL11 OW r• y LIABILITY INSURANCE POLICY I OTHER TYPE INDEMNITY 1.,: } 20 2 i BO1 I�'ti::.,--,'�' OWNER'S INSURANCE WAIVER; I am aware that the licensee does not have the insurance coverage re ui e -J gI��E R P WMENT k 3 Massachusetts General Laws, and that my signature. on this permit application waives this requirement, eyi. CHECK ONE ONLY: OWNER 1. ,a.1 AGENT C. ,, SIGNATURE OF OWNER OR AGENTI 4 i I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat e best of my knowledge andthat all plumbing work and Installations performed under the permit Issued for this application will be in compliance wit P I rev' 'on of the i Massachusetts State Plumbing Code and Chapter f42 of the General Laws. PLUMBER-GASFITTER NAME[spencer Hallett LICENSE# 16224 . SI f4FRE MP 1 MGF L. JP E JGF C LPGI CORPORATION �#18. 4wM�_ . PARTNERSHIP . # .� C v COMPANY NAME: Spencer I�alleil plumbing and Heat,, IncDDRESS[381 O d F 1 _ i Falmouth Rd Unit 3s : I ar tons Mills STATEIlea- .._ ZIP0213 $ 'TEL5t�8-d28-6064— ,-,.,��... a 4 FAX 1508-42-8:19-9-1--1 CELL. EMAIL spencer@hallett lumbin .tom .1_•...-,. --. , mow_ ,Ta:T:�-•_•-..^'.�•:'•i .... _,....._---.... ._.... - -..--L c5 (g ! 1 1 t 7 4 _- i } F+ • "qa..f': Gin,f:postg.y �'2F.5 kt_..4 . „,..„,_,_,.„...• Workers.' Compensation • eeAida-ib ders/lContraet01s/E ec?rac /Pl bees zaiiao/fndividn;l?: S enter Hallett Plumbing and PleaseI left is e - • • :bane- ��� ' Address: Heating - __ ' 381 Old Falmouth Road Suite 36 - • CIty/State/Zip: Mansions Mills MA 02648 ____ Are yen ax.employer?Check the.e appropriate t o . ' Phone#: 508-428-6080 1.1171ram a enTplayer with 11 4. DI am a gbzural contractor andI Type cfpro sect(roved): )e have hires the sub-contactors 6. 0-New construction employees(full and/or paw 2.D I am a sole proprietor or p ; Its on the attached sheet ship and have no employees !�ese sub colic ors have 7 Remodeling working- for me in any capacity. employees and have worker' 8. ❑-Building uflDeb-d g on . bra Rockers'comp.insurance comp. ra ce 9. Building adn ion regmredl] 5. J We are a corporation azd its I0_❑Electrical 3.D Tam a lomeawner doing ail wort officers have exercised their mP airs or additions myself [No Workers'corm. • rigbf of exemption perMGL tl.[�j PI-ambinRoofre g repairs or additions s-LI:74 ce regtured.J f C. I52,§I(4.),and we have no Roof repairs i et<tPloyess [No worers' 13.[]Other �,., Camp.insurance requhed.l 'An,.I applicant th2,t c.ht 5 box#1 aunt also 721 m ttine sontioa below shcnving'their A'orkcIs'mameasseiioa policy information. f F3'pmcogacrs who submit this affidavit indicating they ate do' ng an work and 1-Continuants that cb=I:this box mast ariachcd an additional sheet shoes tint s oft outside sob- ountracontactors or m s submit.a acvt of those Bach employes, If the sob-taatrantors have eaaloyc ,th = a�of the policy rnn nrs d stair y etba or not those L fi�have e3' provide then worlcea'cps pohp member. - 1'cun an employer that is providing workers'compensation vsurance for. infonrzon 'employees. Below is*he poFicy a zd job site Iusurarme Company Name: The Hartford Policy#orSelfins.Lic.#: 08 WEC AE8R'GA /� ,, " EiraionDate: 2/22/2021 Job Site Address S l I V Q( (�a state/ET: - �y /y�, Attach a copy of the workers'compensation policy declaration • page ' / �/z////�� • Failure to secure cove e as r (showing the policy number and expiration date). required wader Section.25A of MGL c.152 can lead to the imposition fine up to$L500.00 and/or one-year imprisonm ent,as well ases WcriminalORDER ties of a of up to$250.00 a day against the violRtor. Be advised that a copyof this in the forth beof a STOP WORK ORDER andafne Investigations of the DIA for' ce coverage vecation s�aL*reot may forwarded to the Oz�ice of Xdo hereby t:erLify zazt4,7jie ofpe fu y that the information provided above is true and corre Sienature: _- r� Date: 17 I z / Z o Z a Phone#: 508-428-6080 Official use only_ Do not write in this areg to be caram, `���by or town official • City or Town: Permit/License# Issuing Anatol ity(circle one): I.Board of Health 2.Builrthrg Department 3.City/Town Clerk 4.Mectrical Inspector 5..PIurub• 6.Other mg.inspecto;' • Contact Peron: Phone