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HomeMy WebLinkAboutBLDP&G-21-001577 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK s/ CITY YARMOUTH MA DATE 9/25/20 PERMIT# BLDP-21-001577 .l' Jt JOBSITE ADDRESS 18 SPINNAKER LN OWNER'S NAME SMITH GREGORY H P OWNER ADDRESS SMITH TINA M 18 SPINNAKER LN YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL Ea PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES ..i FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING 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 TYPE 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'S NAME ANDREW LEVESQUE LICENSE t6162 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME HARWICHPORT HEATING AND ADDRESS 461 LOWER COUNTY ROAD _COOLING CITY HARWICHPORT STATE IMA ZIP 02646 TEL FAX CELL EMAIL andy@hphcllc.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES • Yes No THIS APPLICATION SERVE AS THE PERMIT FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYIrowN YARMOUTH PORT MA DATE 9/15/2020 PERMIT# BCDPr1I-6p,4S-j7 JOBSITEADDRESS 18 SPINNAKER LANE OWNER'S NAME SMITH P , OWNER ADDRESS 18 SPINNAKER LANE TEL 508-375-0995 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL a PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[J PLANS SUBMITTED: YES El NO❑ FIXTURES 7- FLOOR—) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB • CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK ' TOILET URINAL WASHING MACHINE CONNECTION • WATER HEATER ALL TYPES 1 WATER PIPING OTHER INSURANCE COVERAGE I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL,Ch.142 YES EYNO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 13' OTHER TYPE INQEMNITY❑ BOND ❑ OWNER'S INSURANCE WAIVER.,lam 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 ONLY1 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 LICENSE# L15162 Andrew LevesqueP GidAT.0 MP[Vj MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC gf# 3944 COMPANY NAME Harwich Port Heating&Cooling LLC ADDRESS 461 Lower County Rd CITY Harwich-Port STATE MA zip 02646 TEL 508-432-3959 FAX 508-432-6075 CELL 508-958-4874 EMAIL andy@hphcllc.com kecia@hphcllc.com • ;I_ J . t z The Commonwealth of Massachusetts 1 Department of Industrial Accidents Office of Investigations k.:15v '', 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 1 Name(Business/organization/Individual): Harwich Port Heating&Cooling LLC 4 I Address: 461 Lower County Road i t City/State/Zip: Harwich Port MA 02646 Phone#: 508-432-3959 ` Are you an employer?Check the appropriate box: Type of project(required): I 1,2 I am a employer with 75 4. ❑ I am a general contractor and I 6 New construction i employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner.- listed on the attached sheet. 7. [Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' $ [No workers'comp.insurance comp.insurance. # 9. 2 Building addition required.] - 5• El We are a corporation and its 10.12 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.g Plumbing repairs or additions myself.[No workers' right ght of exemption per MGL 12.0 Roof repairs insurance required.]t C. 152,§1(4),and we have no 9 employees.[No workers' 13.[Other HVAC comp.insurance required.] *Any applicant that checks box#1 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 number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Selective Insurance Company of South Carolina Policy 4 or Self-ins.Lic.#: WC9059813 Expiration Date: 10/26/2020 Job Site Address: 18 SPINNAKER LANE City/State/Zip: YARMOUTH PORT, MA 02675 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. I do hereby care nd ' a d penalties ofperJury that the information provided above is true and correct. 1 Signature: Date: 9/15/2020 Phone#F: 508-432-3959 Official use only. Do not write in this area,to be completed by city or town official. t City or Town: Permit/License II Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 0: - It i 4 L - , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a . CITY YARMOUTH MA DATE September 25,202 PERMIT# BLDP 21 001577 r= JOBSITE ADDRESS 18 SPINNAKER LN OWNER'S NAME SMITH GREGORY H G OWNER ADDRESS SMITH TINA M 18 SPINNAKER LN YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 - 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 1 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 ANDREW LEVESQUE LICENSE# 15162 SIGNATURE MP© MGF El JP❑ JGF El LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: HARWICHPORT HEATING AND COOLING ADDRESS. 461 LOWER COUNTY ROAD, CITY HARWICHPORT STATE MA ZIP 02646 TEL FAX CELL EMAIL andy(a)hphcllc.com 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 tip ciTY YARMOUTH PORT MA DATE 9/15/70?0 PERMIT# 4 U P--Zi.--oDlS7 JOBSITEADDRESS 18 SPINNAKER LANE OWNER'S NAME SMITH GOWNER ADDRESS 18 SPINNAKER LANE TEL 508-375-0995 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(it PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:® PLANS SUBMITTED: YES 0 NO 0 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/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Er/NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I 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 detaHs 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 Andrew Levesque LICENSE# PL15162 ( ter GNAT MP g MGF& JP 0 JGF❑ LPG!❑ CORPORATION 0# PARTNERSHIP❑# LLC g# 3944 COMPANY NAME Harwich Port Heating & Cooling LLC ADDRESS 461 Lower County Rd CITY Harwich Port STATE MA ZIP 02646 TEL 508-432-3959 FAX 508-432-6075 CELL 508-958-4874 EMAIL andy(a,hphcinc.com