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HomeMy WebLinkAboutBLDG-25-607 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 5 ;i lit.PI.1y7(.; MA DATE kIJU 3 Zoe, PERMIT# j-- 2 4D JOBSITE ADDRESS y 3 Av T:::)-j,.., OWNER'S NAME GOWNER ADDRESS TEL J Z ' U e3ys FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL�— PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z 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 L No . '2025 UNIT HEATER UNVENTED ROOM HEATER ► _--.. -_ _ WATER HEATER a BUILuiCJi . . ur OTHER INSURANCE COVERAGE I have a current liabilit'Linsurance 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Cv iit.•,/.-1, ke,/-7., j' LICENSE#/Z,;2/ `. - SIGNATURE MP ." MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC # COMPANY NAME: • // Sen 6/,cc 6 ADDRESS / j cv,-.v ry / - 10 CITY �t�`-e S i W* STATE *7/7- ZIP 02 C 6 TEL 3-di 3-di >7 6 /o�FAX CELL -7 7' ('.7 EMAIL %�./7f 4).9-r330 C" .5 ..�.�,� /Jo -----� Department of Industrial Accidents kOffice of Investigations _u: `' Lafayette City Center `b 2Avenue de Lafayette,Boston,MA 02111-1750 = _�' www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): WI Li t 4 Wt i-trA .. 0 6 4 S 4 1c J('e/ j I (.( Co Address: i'�3 (0tir,11-y /Zor44 City/State/Zip:jjj e r u.)A''U .Lt 4.s-) 04 Phone#:_ SD 5 -77 b - /0 0 r Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with 4. ❑I am a general contractor and I _,employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.M41 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor in capacity. employees and have workers' El me any 9. Building addition [No workers'comp.insurancerom p'inswance.t 10.0Electrical repairs or additions required.] 5.❑We are a corporation and its P 3.0 I am a homeowner doing all work officers have exercised their 11.2flumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]* c.152,§1(4),and we have no employees.[No workers' 13.LOther 7 C comp.insurance required.] .Any applicant that checks box it'must also fill out the section below showing their workers compensation policy information. T Homeowners who submit this affidavit indicating they are doing all 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 member. I am an employer that is providing workers'compensation insurance for nip employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition 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. L I do hereby certify under the pains and penalties ofperjmy that the information provided above is true and correct. p1 Signature: [/`1✓ Date: Nati 3 Zo 2`s- Phone#: 5 , - 7'7L — /00S" Official use only.Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5E1plumbing Inspector 6.❑Other Contact Person: Phone#: �-� B&HSERV-01 MRAYMOND ,a►CORv CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/28/2025 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). CONTACT PRODUCER NAME: Almeida & Carlson Insurance Agency, Inc PHONE 508 540-6161 FAX 457-7660 79 Davis Straits (Arc,No,Ext): ( ) (arc,No):( ) Falmouth, MA 02540 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:HARTFORD ACCID & IND CO 22357 INSURED INSURER B :The Fairway Agency William Heath DBA B & H Service Company INSURER C : 153 County Road INSURER D : West Wareham, MA 02576 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 08SBMBR7LPR 4/12/2025 4/12/2026 DAMAGE TOEa RENTED occurrence) $ 1,000,000 PREMISES( MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT Business Liability General Aggre OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY __ AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION PPER ATUTE ER OTH AND EMPLOYERS' LIABILITY Y/N WCC50050293072025A 6/1/2025 6/1/2026 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N N l A E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 1,000,000 (Mandatory in NH) E.L. DISEASE-EA EMPLOYEE $ If yes, describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD