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HomeMy WebLinkAboutBLDG-21-004442 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE February 05,2021 PERMIT# BLDG-21-004442 JOBSITE ADDRESS 22 SETUCKET RD OWNER'S NAME VARJIAN KATHRYN G OWNER ADDRESS PO BOX 216 CENTERVILLE MA 02632 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 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 1 • DIRECT VENT HEATER DRYER 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❑ 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 ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: SPENCER HALLETT ADDRESS. 381 Old Falmouth Rd Unit 36, CITY MARSTONS MLS STATE MA ZIP 026481372 TEL FAX CELL EMAIL spencers hallettplumbing.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTIONAIOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES • 1p_ \ EVIASSACi LISE't TS UNIFORM APPLICATION! FOR A PERMIT TO PERFORM GAS IJl T T INt WORK to CITY ;.Ya.I;1mQ:utzht� _s MA DATE�� TZO2'� _. : PERMIT# F3L �-'�`C�/�I`t Z ' 1 p :... .-- ��:. _ .^,+::. ..zi^}vlc: .::1rw:n.�:..tiaas+L\•_ :.lT:•:3.::._+eeti'i^::J:JCiL•:C.as�.--,: 2 t753, JOESITE ADDRESS�. 22Setucket Rd-,�.�......._�----..__---• o E. _ _ ....r.•�.,..,r,.,..�a....,.._.....,...,:--..__-._..�,�__._.^:�. ----- - ,,:.._f:__.___„.ti,..f:..V_,nc :.:�,:.__.�r.e_.,�.0 WN R'S NAME : V r� n t /, + .......:........:....:.1_ ... _.«,_ ^�-.'�n/C••.:.1•d_,_.F..=C71dLi:%�......�t-7l-RAMC:.\_)34U. IV2 . F :...2.. ...m.r T1 OWNER ADDRESS L . Rd �.Yarmouth_ Port _--_ TFi1,.� • •: JFAX .�. ..•.•..•. ••i i/):Js�'A-C1+v.-Fn!.112.,?1:- 77.7,Tw.1,:•1,c:-1+2=M47_: TYPE OR Pam, OCCUPANCYTYPE COMMERCIALJ.,_ I EDUCATIONAL. RESIDENTIAL CE,EARLY NEW: ( .� RENOVATIOU:J.s._, REPLACEMENT: PLANS SUBMIT ,.... TED: YES n' NO _ .: € APPLIANCES 1 FLOORS- BSA 1 2 3 4 5 G 7 8 0 _ 10 11 _ _ 12 13 14 t BOILER _......._.[ `..___a,ti.._..._..:..��___ —iR�_.�T ,.___ _ ..... , l__� j.�__..•�,..�.. �`-Mt:.. :.:..J.,-u-a =-__r't _A _ .....::.,`'I, .'�'•_..M1..et O� `..Fa . .�'I__ d`.�. 'i,.. _.;4f ; —.. ... a-� L_�. -..,,., . - _.._,.,, ,__�. _ - ._.. L _ BOOSTER �:�.__.::�I-��.. I� C.. ��i::� _.W�t�.. _ �I.:.. ��C.�- _�.��-- s iy _ ::-�� j f CONVERSION BURNER �`� i �- _ - ---- ___..._._-� - ._._. ���:.. ..•_- i - L:+r,r�,r2kn. -_,.. ? ( -- te2 ram..__ Ia-.-::a,a r--`�I'r^.-:.�- 1....��..J.I .��..--- -'= Yaw�.�_i - >t�_i.:a-n!�.� 2 COOK STOVE I ��I,._1., ..11.s _ �,•I�--�_Ll,l.'_.w..., � i .�:. :_ � ..�-_�, _._ .---._ , _.._._ k�•.___�.- :;;-_ _ - •.t _ _, I-`-s—f.M 1 Ir.r V:..=.'I"",".=---''="7— -,,^.-11., Y,,,-. ,�-':E,..:.... ;I.—..n..---,j.,� - ;,--2 f.,�-••--_ DIRECT VENT HEATER . .::_ , .. �" ,l ., :,_ .� .__.; z -. ,._.,. ri f.- irk'!: ;(^. I I...:,., ..l n:.-: •i I�_ a-i Jr— _: :- :„ f , ; i DRYER - , #. a._.._'�_. �._ _,�.s�., _ -,V.w. ...._.-. ' 1'' _._r `z. J C:__ w�?I__.".: 1 fi1REPLACE • ��_. ..--:I.._. . . l .....r_. ._ •- .� ...n,.... .—:...—..i I.-_•• 1 I ----1 -.._: �- � ... I � ,r. '' ..... -- ...:..,...-may'` 3 /'1r"' •' ..... r'_ _ lei ,ak.•:�t` 1- r::,:••.•�n•_y.- f__• -...._ ....��, -,4 _i..- ..)f.. ''r FRYO!_AT rt r-a- '1 - _ :a._---s . ..-. .;..._: :_ !- -Y...� ,. _.�.� 1_ {,. :a Ir:, _ 1.I: - 1.-- :1 LY._ - '; :7,- ---f[ ,:�: .?r.- ,.:2 ;; ,.1 t,•r.:_...:. C::_. :31w:7_.�..4C_� —=1 , .i T. FURNACE .= 11 s..�.> :,1 1 -II_ -11 _ i__...........,. - -, --, _,.. ..._/ j .:._ :i r.,._.., - il GENERATOR I. Y _ii if ▪ � I�r .�E:. '���. _ . �,�—��-• -- I. �fW��-._tl� ..,:. i_,...:.r�rir�_.r�, �_,...:,..:�I :�_..: GRILLE — r_ :�J I _ :�_ �;;�.� �,_ _ :; r M �.��� I.,,z.Y _.:: I�s...,.:._ r� I_.. I:,..�r..----��r E:R —_ INFRARED HEATER ..___:., „_� �,_ _. :.� _.,.� __.-, ,,: ___ 1I..�._11. - T i I. I� (�:::: F: -f , :=irk _ S — 1 �iri LABORATORY COCKS -•_' .ry - , .-:...r..„ . .__ ._ _ �u�� C .�Ir-•�--,[�_ w,..-I- rK—. l~:�:,:, MAKEUP AIR UNIT C 'i�....�.�I I.� �t 1„ I-._ I L-- I I^ .,-i f_:_�_-i ��_^fj �1 . �.__�; . ___,' --, �, •.-i�'��� _oa•1�.�+.� ___8 ,.�_r,.. _..� _ _r:� ,�:- ..__., -: I:ti .,•..,1 I• .,-. .; la ..-,.•,•.1 I. n OVEN —` - { , - _ �� _ -.� - :,, �_ 3 ;f_ �, E POOL.HEATER __- !:_ :.._..�., -- -•- f.�.:,:=1 _ -_ 1�-,:..x_I,y.-. �_:r.•. .._.,, _ I• _.,,.� I. .:r._,!4.� ref V..,-r t.�f. - t�.....y..—•...,� ' _ �, ` f .=.! .E �� =r •i ROOM 1 SPACE HEATER1�I,-. ���.,.,,,.. _ —' ~� � I.r=.., • �_. I.�� {1' :__. i I�.,,. . I.:s _ --"i Ir.,, --'t•tl _. c:. ..,i s,....r; E.,,- ti 1�_:r m, I_ __.7 �a r - ROOFTOP UNIT 1•_._ II.;,, ., 1 r �.ir ,- (,__ _ rlf-. = 11�.,.�__:1.�..�... 1Ir. I m„� f�...,.�:�..�� I. 11... _s TEST �-•t ..___ -._- a F� P. v_ -a I.�y-,�. Ii II II s UNIT HEATER I ▪ 1} - 3I_ IL :,�� � I_ __�'� �_ ; UNVENTED ROOM HEATER ;:.. . tl 7 -:�...I _ �.. ��.� , __� ___ ,�.--=:C,-.,,....f ��,� =al I. ,Ir ;f_.� i I ,1 t .w_� ,r.. _ _J _.r _�i 1 WATER HEATER �-: :�{, ..._ -�.b�,.: n..�_ --: .': _ _•_ .� 50. . _,-_ 1_..,,. 1 L�._._. I~..,, r,'.,•..• - .., f. OTHER i I,.:,...,..• .i i i�.,rr....,. l .�., I _ .�. _, .._ _ --r-_ �_ -._,.- 11— gEmes�-f'W: ��azt.. a..=%5!i,i:'i.w.L4'-riL_.=%;�r y�-•'' 2:n2- :c .,..__- m..;• .._.. :4.:-._ a,. "...:!:'I~_•.-- _ .tea=:'- ',w...•. rriI :. "•i;,. -11T•..,t ,—IF _ 1 • fl it }��.a.asp,�•sa::.�tvx•�:,x.:cy::c:r:�-s����s���-..._::,.: ...............il.�;r.�„•.r;1,_---a _�-I •.....,..:.i1c._::.=,ail:..`_";fE : tzi •• :e::` ,j - . ;`r.•wi w- 1^.__._i _1 !t _1(y''` I J..„.' �1 �a+..•_v.,=r_ . .,Tfa...�_�. .:r,..- • :_ ... .., ---.:._t C_.r.�,.,•.,,ti,n�...,—•I f INSURANCE COVERAGE Li I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. '142 YES L NO j I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW p. LIABILITY INSURANCE POLICY ;v. OTHER TYPE INDEMNITY Iv BOND F ,i OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have The insurance coverage required by Chapter 142 of the 4 Massachusetts General Laws, and that my signature• on this permit application waives this requirement, . CHECK ONE ONLY: OWNER [TILL AGENT �.:_, t SIGNATURE OF OWNER OR AGENT l I hereby certify that all of the details and information! have submitted or entered regarding this application are true and accur t e best of my knowledge . 1 and that all plumbing work and installations performed under the permit Issued for this application will be in compliance w'rt I pvi on 4T � -• ' ' �' 't = Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • PLUMBER-GASFITTER NAME Spencer Hallett LICENSE#I1116224 SI RF T i MP MOF �_ JP JGF f PGl i�._T CORPORATIONr3-8-34.wM�� PARTNERSHIP #,..............,r1 � a COMPANY NAME: Spencer Hallett Plumbing and Heating , Inc ADDRESS I381 Old Falmouth Rd unit 36 �`�_ �-- w���' .... .- w __ _--- -��:.... _ ... __ BUILDING D E_!'ART , CITY �Marstons Mills _.._�. ..__. STATE ^Ma� Z1P02648 r-_ TEL _.,. �. _ux; ,..:;a.:;.:.�� _ �' __...r,_�. .. _�.-. ......_�...__.._w� _ __ __ T -- _}T L 508-42 -8U88 — FAX 508-428 7991w ^ CEt.LL :. ,EMAIL spencer@halleifplumbing.com ____., :w ,_. _�.. w__.._�__�.._._ _.� _:� w:�..__..._ ., - sS •_ g[[ t 1 i i S . ��_ — Z %fi r t_fiC t liw+� E`II t,G.;rid•,;!;.: I A • 60c0 ,k�fi=�li.k g edit.5 rG' . f t r ! 7) ad 1�\ e--.?�zrt Boston,Gre+di'L�Aral 02 i.0 Workkrs'Comp enafton tau ance.A d tTxiz- derskCoufr torsT ec cinslk° abers .Applicant InformationP lease Vans LeOblv.' •Name-(Bisizesstorga on/rndivid.RD: Spencer Hallett Plumbing and Heating l Address: • 381 Old Falmouth Road, Suite 36 • E i • City/State/Zip: Marsfons Mills, MA 02648 Phone#: 508-428-6080 Are you anes employer?Check the appropriate bow ' - Type ofproJect( e •1.[J Lam a employer With 11 4. ❑I am a gwEaal contractor and I d}: E employees(firil and/or part Vie). have him the sub-contactors 6. DNow construction 2.❑ I am tr a sale proprietor or p�iuez 1is d.cm the am-Ached sheet 7. L R nodeti ship and have no employees These sub contiactoxs have g, ❑Deinolkion 5 working forme in arty capacity employees and have workers' S [No'workers'comp.insurancecomp.insurance a 9• ❑Building addirtiotl reguirec ] 5. El We are a corporation and its 1D_❑Blectricai repairs or additions t1 3.Ell I am a horneovmer doing ail vrnrk officers have exercised their 11,D plumbing repairs or additions . nrysel£(N'o workers'comp. . right of exemption per MGL 12.0 Roof insurance reguke 7 1 t e. 152,§1(4),and we have no employees.[No wn ers' D.0 Otlier comp_insurance regrired.) 1 i"may applicant that cheeks box#I most also fill outthe section below showin;fac'uworkerz'compionsaticm policy information. t Hameomers who submit this affidavit indicatnig they am doing all work and they hum outside mzilractors roust submit anew alIIdar;z indieatbog sack. $Conizactrus that check this box must attached on additional rhrrt showiegthe name of the soh-contrrclnrs and stain y etha-or not those entities have • i employes. Mlle soh-=Morslam=ploycc;they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for tray employees. Below is the policy and job site . information. Insurance Company Name: The Hartford Policy it or Set ins.Lie. 08 WEC AE8RGA Expiration Date: 2/22/2021 Yob Site Address: 22 Setucket Rd S'/ :Yarmouth Port, MA 02675 Attach a copy of the workers'compensation policy declaration page(showing epolicynumber and • Failure to secure coverage as criexpminal penalties sofa rag required Section afMGL c.152 can lead to the imposition of crimhzalpenalfies 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 fore 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 fox inst nce coverage vet fl tion. I do hereby car*unrl ze ofperjray that the information provided above is true and correct. Simat re: Die: 1/26/2021 Phone it: 508-428-6080 ' . Official use only. Do not itezte in this area,to he cone rpfed by 'city or toiwz official City or own; Permi;t-/3License## _ issuing Authority(circle one): 1.Board of Health 2.BnildingDepartrnent 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector t 6.Other Contact Person: • Phone#: • 1