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Home My WebLink AboutBLDG-21-004651 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK E CITY YARMOUTH MA DATE February 16,2021 PERMIT# BLDG-21-004651 tl JOBSITE ADDRESS 184 SOUTH SEA AVE UNIT 15 OWNER'S NAME DANTUONO ROBERT R TRS G OWNER ADDRESS DANTUONO DEBRA TRS 20 CAROL CIR EAST BRIDGEWATER MA 02333 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑ FIXTURES FLOORS--* BSM 1 2 3 4 5 1 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 I 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 0 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 Paul Viera LICENSE# 26989 SIGNATURE MP 0 MGF ❑ JP© JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: 'Paul A Viera ADDRESS. 13 SHADY DR, CITY HARWICH I STATE MA ZIP 026452930 TEL I FAX I I CELL I I EMAIL ` I 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 c • ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK j) ._j-_)V CITY: Ni air ben ca<J 1-1.‘ MA. DATE g-—1'�3 -2\ PERMIT# aLDC—Zr--0c)% t a-: JOBSITE ADDRESS:18'1 S i S G A Avg' OWNER'S NAME Bc 13 A y 4.ti oh 0 g L7( 1 C 44"4. #L" I S OWNER ADDRESS: TEL:5O8-9 0 'Ili FAX: 5.— TPPE OOR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIALEI., CLEARLY NEW:0 RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 APPLIANCESZ FLOOR-, 1 2 3 4 5 6 _7, 8 9 10 11 12 13 14 BOILER BOOSTER -- _ _ CONVERSION BURNER :---if COOK STOVE '- DIRECT VENT HEATER 0 DRYER t FIREPLACE _ + FRYOLATOR FURNACE 0Q-. GENERATOR _ ,, GRILLE _ . SA INFRARED HEATER . rul LABORATORY COCK , , , MAKEUP AIR UNIT rl OVEN POOL HEATER ROOM 1 SPACE HEATER .,�J ROOF TOP UNIT .t TEST .Z UNIT HEATER _ t4j UNVENTED ROOM HEATER WATER HEATER r X. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 15410 0 If you have checked Yna,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY a--- 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 0 AGENT 0 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 pewit issued fortis ap. ,,. ,: ll pliai4e,f1111 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � 11111 . /—/ PLUMBERIGASFTTTER NAMEPI�t) V(� co... LICENSE#U6t g 1 SIGNATURE COMPANY NAME:PIA kPl. t`U I S 3 �v\,_ ADDRESS: S\'1G-�� D iz-- CITY: 1_,--4 G.f,..r--; C.-� STA •M A ZIP:0l Co q S— FAX TEL 7hg-y3Z-99y CELL:77V 5C-/5-cjL EMAIL: MASTER 0 JOURNEYMAICEfrtP INSTALLER❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# Eiiic, ADDizess:rPY4utS 2(uw\30%Y‘y ".o @ a�C,o .cowl, 1 w A f l • 6 The Commonwealth of Massachusetts ►"_. '/ Department of Industrial Accidents 1 Congress Street,Suite 100 • _'a i t. Boston, MA 02114-2017 4<t www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): RICK/ 'P W\.t ra t Address: 3 j V.0..c9-.c.5 p(� r City/State/Zip: .rw: CN\ M'kt o2Io11C- Phone#: 7? 9— /S 9 Z Are you an employer?Check the appropriate box: Typeof project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance? I3.❑Roof repairs 6.0 We am a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'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: 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 MGL c. 152,§25A is a criminal violation punichAble by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert fy under the pains� andme penalties of perjury that the information provided above is true and correct Si ature• a---4 l/ie Date: Z--I S-Z Phone#: 77 V— S35--/S`7 0— Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# 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#: i -. � ` ` LU IM ' ~~ U. LLI cc Ul uj — cz � CO ui ' • ® 144APFFIE INSURANCE4 MAPFRE Insurance Company 11 Gore Road, Webster, MA 01570 BUSINESSOWNERS RENEWAL POLICY Renewal POLICY NO: 8008030008482 RENEWAL OF 8008030008482 Agency Code : 20688 ACCOUNT NUMBER: NAMED INSURED AND MAILING ADDRESS AGENCY AND MAILING ADDRESS PAUL VIERA DBA PAULS PLUMBING AND HEA KAPLANSKY INSURANCE AGENCY, INC. 3 SHADY DRIVE 8 MAIN STREET, P.O. BOX 2743 HARWICH,MA 02645 ORLEANS, MA 02653 POLICY PERIOD: FROM 09/13/2020 TO 09/13/2021 AT 12:01 AM STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE. THE NAMED INSURED IS: Individual BUSINESS DESCRIPTION: **CONTRACTOR ADVANCED PREMIUM. YOUR POLICY MAY BE AUDITED. IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. DESCRIBED PREMISES Prem. Bldg. No. No. Premises Address: 1 1 3 SHADY DR, Harwich, MA 02645 SECTION I—PROPERTY Business Type Of Property Personal (Building Or Actual Cash Automatic Property— Business And Value Of Increase Bldg. Seasonal Prem. Bldg. Classification Personal Bldg. Option Limit Increase Limit Of _ No. No. No. Property) (Yes Or No) (Percentage)** (Percentage) Insurance* Premium 1 1 1 Business No % 25% $5,000 $102 Personal Property US DEC 1000 12 15 Page 1 of 4 0 MAPFRE I NSURANC BUSINESSOWNERS RENEWAL POLICY Renewal POLICY NO: 8008030008482 EFFECTIVE DATE: 09/13/2020 INSURED: PAUL VIERA DBA PAULS PLUMBING AND AGENT: KAPLANSKY INSURANCE AGENCY, INC. HEA Deductibles (Apply Per Location, Per Occurrence) Optional Coverage (Other Than Equipment Breakdown Protection Coverage) Windstorm Or Hail Prem. No. Property Deductible Deductible Percentage Deductible (Location 1, $ 500 $ 500 N/A % Building 1) Additional Coverages—Optional Higher Limits/Extended Number Of Days (Per Policy) Limit Of Insurance/Extended Coverage Additional Premium Number Of Days Employee Dishonesty $ 68 $ 10,000 Optional Coverages (Applicable only if an "X" is shown in the boxes below) Location: 1 Coverage Limit Of Insurance 1. Outdoor Signs $ Per Occurrence 2. x Money And Securities $ 10,000 Inside The Premises $ 5,000 Outside The Premises 3. x Employee Dishonesty 10,000 Per Occurrence 4. Equipment Breakdown Protection Excluded Coverage 5. Burglary And Robbery (Named Peril Endorsement only) Money And Securities $ Inside The Premises (Amount included when Burglary $ Outside The Premises And Robbery Option Is Selected) US DEC 1000 12 15 Page 2 of 4 INSURANCE' BUSINESSOWNERS RENEWAL POLICY Renewal POLICY NO: 8008030008482 EFFECTIVE DATE: 09/13/2020 INSURED: PAUL VIERA DBA PAULS PLUMBING AND AGENT: KAPLANSKY INSURANCE AGENCY, INC. HEA Location: 1 Coverage Limit Of Insurance 6. Fire Department Service Charge $ 7. Mold -Fungi,Wet Rot Or Dry Rot $ 8. Water Back-up And Sump Overflow $ Covered Property Limit $ Business Income Limit SECTION II—LIABILITY AND MEDICAL EXPENSES Each paid claim for the following coverages reduces the amount of insurance we provide during the applicable annual period. Please refer to Section II—Liability in the Businessowners Coverage Form and any attached endorsements. Location: (Location 1, Building 1) Coverage Limit Of Insurance Liability And Medical Expenses $ 1,000,000 Per Occurrence Medical Expenses $ 5,000 Per Person Damage To Premises Rented To You $ 100,000 Any One Premises Other Than Products/Completed Operations $ 2,000,000 Aggregate Products/Completed Operations Aggregate $ 2,000,000 Liability Premium $ 1,350 Deductible Optional Property Damage Liability Deductible: $ 500 US DEC 1000 12 15 Page 3 of 4 NIAPFRE I INSURANCE' BUSINESSOWNERS RENEWAL POLICY Renewal POLICY NO: 8008030008482 EFFECTIVE DATE: 09/13/2020 INSURED: PAUL VIERA DBA PAULS PLUMBING AND AGENT: KAPLANSKY INSURANCE AGENCY, INC. HEA Deductible Per Claim (Refer to BP 07 03); or x Per Occurrence (Refer to BP 07 04) Coverage Annual Premium Transaction Premium _ Terrorism $ 0 $ 0 Premium for Endorsements $ 174 TOTAL BUSINESSOWNERS POLICY PREMIUM $ 1,694 TOTAL PREMIUM $ 1,694.00 FORMS AND ENDORSEMENTS APPLYING TO THIS COVERAGE PART AND MADE PART OF THIS POLICY AT TIME OF ISSUE: See Forms Schedule NOTE: IF NO ENTRY APPEARS ON THE ABOVE ENDORSEMENTS, INFORMATION REQUIRED TO COMPLETE THE FORM WILL BE SHOWN ON THE SUPPLEMENTAL FORM DECLARATION IMMEDIATELY FOLLOWING THE APPLICABLE ENDORSEMENT. THESE DECLARATIONS, IF APPLICABLE, TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE FORM(S)AND ENDORSEMENTS,AND SUPPLEMENTAL FORM DECLARATION(S), IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY US DEC 1000 12 15 Page 4 of 4