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HomeMy WebLinkAboutBLDG-21-001150 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,� '(.1 CITY YARMOUTH MA DATE September 03,202 PERMIT# BLDG-21-001150 JOBSITE ADDRESS 20 BUTLER AVE OWNER'S NAME ENGLISH DONNA A G OWNER ADDRESS CIO VINCENT ENGLISH 2 LAN RD SANDWICH MA 02563 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 FIXTURES FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 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 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 (Dennis Earle LICENSE# 15795 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPG' 11 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Dennis A Earle ADDRESS. PO BOX 876, CITY (SANDWICH STATE MA ZIP 025630876 TEL I FAX CELL EMAIL r�- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No RIG oh- 9I30l2otd THIS APPLICATION SERVES AS THE PERMIT El El c70 0 0 I,3 2. FEE: $ PERMIT# PLAN REVIEW NOTES ...._ - - •.... ".. MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM OAS FITTING WORK Ir••;/ CITY: $'eS7 Kg Mocil-)- MA DATE0115. . 0 ZO Pours eih&--91-tims-D , "Peonke. x?eivz7,-9 JossrrE ADDRESS 2-0 ese7-l ie k .i,ire OWNER'S HAW OWNER ADDRESS: TEL FAX TYPE OR OCCUPANCY Type COW/ERCIAL 0 EDUCATIONAL 0 RESIDENTIAL)K PRINT CLEARLY NEW:0 RENOVATION:EI REPLACEMENT:Er' PLANS sumarrexiisso NOD APPLIANCES1 FLOOR-* Wt 1 2 3 4 , 5 6 7_ . 8 9 10 , 11 12 13 14 BOILER COWERSION BURIBM . COOK STOVE - • ' .DRECT VENT HEATER DRYER . REPLACE 41YOIATOR . . .. , FURNACE GEPERATOR s% .GFILE L .. .. . . _ M [HAWED HEATER 2 V, LABORATORY COOK . . .- uP . , . - , • OVEN CI POOL-HEATER — ..- 1 ROOM! CHEATER ...SI ROOF TOP MR VI- TEST Z 'UNIT HEATSI IQ thIVENIED ItOCOA HEATER .WATER HEATER .. . INSURANCE COVERAGE I have-a mitt ItehMtv Munnce poky or its.substantial equivalont whiff meets the requirements of-MGL.Ch.142 YES 0 NO 0 If you have checked)ZS,please indicate the-type of coverage by checking theappopriale box belme. Marry INSURANCE POUCY 0 OTHER TYPE tripiwirrY O BOND 0 OWNER'S INSURANCE WAIVER:tan aware entitle licensee fignagthreg the MUMS causing°reqUired.by Chapter 142 oils Massechusetts General Laws,and that my signatuts Ofk tits pert application gn this requbement. CHECK ONE ONLY: OWNER 0 AGENT 0 . SIGNATURE OF OWNER OR AGENT . . hereby(*MY that all of the detak and information I have submftted(or attend)mgardIng tide application-am ,-. . - .mutate,the beet of my Knuatedge andbat all plumbing%volt and Imbibe=perbmed underlie paint band fortis applicalion .- In..,;,..iiio, vat el Pertinent motion dim Massachusetts State.Plunking Code and Chapter 142 of the General Laws. PLUNIEROLSFITTER NAME Iii II Ic Afeq uceeet./57%- 'SIGNATURE COMPANY NAME:Drr)il 1 3 :laf.t.1 P 4 ii ADDRESS: /g z- coy; . ..4,AN I e M STATE Nit ZIP: 02C63 FAX: TOY ‘3) .cg Y EMAIL MASTER 0 JOURNEYAMN LP NSTALLER 0 CORPORATION 0# PARTNERSHIP 0# acCit Ein&c, ADDRoss: . The Commonwealth of Massachusetts '' _ '• Department of Industrial Accidents 2— y I Congress Street,Suite 100 _ Boston,MA 02114-2017 `-, s www.n .gov/dla Workers'Compensation Insurance Affidavit:Builders/Contractors/Eleetritians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. paolicant Inforption Please Print Letribiy Name(Buaineas/Orpnizetionlindividual): 64 r L5 Address: 1 2 kr 6 A City/State/Zip: SA-iv )c.,4 foJ1• Phone#: J vcc ?/ t9 Are you an employer?Cheek the appropriate box; • Type of project(required): 1.0 I am a empbyer with employees(fall and/or part-time).* 7. 0 New construction 2 i f l em a sole praprieacrar partnnsidp and have no employees wolfing for me in 8. Ej Remodeling any capacity.[No wakens'comp-insane required.] 3.0 I am a homeowner doing all wait myself[No waters'comp.Insurance regain{.]t 9. ❑Demolition 4.01 a m a homeowner and will be hiring contractors to conduct all waft on ray property. I win - 10 0 Building addition ensure that an contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions p aprist=with no employee& 12. 5.0 I am a general contractor and I have hired the wb-eont actoes listed on the attached sheet Roofr These sub-coetractosa have employees and have workers'comp.irmuaaoex t 13.0 iag repairs or additions Roof r sins 6.0 we are a corporation and its Armenhave eereroiaed their right of co mpaiOn per MG c. 14.0 Other 152.i l(4),and we have no employees.[No workers'comp.insuraece required.) *Any applieenthat checks box 11 must also all out the section below showing their wodoera'comparisadon policy bib:mation. t Homeowners who submit this affidavit indicating they ere doing all work and then hire outside coetractots must submit a new af5davit indicating arch kkat aetoes that clear this boot must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have Ifthe a ooattacton have employees.s.they must provide their workers'comp. number. I am an employer that b providing workers'compensation insu once for my employees. Below Is the policy mod Job site taformatlon. Insurance Company Name: _ Policy#or Selfins.Lic.#: Expiration Dare: 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 segue coverage as required under MGL c.152,1125A is a criminal violation punishable by a fine up to S 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 S250.00 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 and penalties of perjury that the information provided above is true and correct Sianature:d Date: " .?1 Phone#: ,O 7,- SLY?'5 • Official use only. Do not write in this area,to be completed by city or town offu al City or Town: Permit/License# r• 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#: