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HomeMy WebLinkAboutBLDG-21-000327 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,1, CITY YARMOUTH MA DATE July 22,2020 PERMIT# BLDG-21-000327 JOBSITE ADDRESS 25 BUCKWOOD DR OWNER'S NAME BENJAMIN ISIDORIO G OWNER ADDRESS 25 BUCKWOOD DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES ❑ NO EI 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 1 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:furnace 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 Timothy Mcelroy LICENSE# 15993 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: TIMOTHY M MCELROY ADDRESS. 107 PINKHAM RD, CITY SANDWICH STATE MA ZIP 025632533 TEL FAX CELL EMAIL 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 /l '1 CITY t Dl/ .Vyt \ n MA DATE PERMIT 0L�Fs 7 JOSSI ADDRESS L c 1(Z.L s OWNER'S NAME I C���V11� GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL a PRLNIT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:121 PLANS SUBMITTED: YES❑ NO 0 APPLIANCES 1 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 M FRYOLATOR _ 1-RECE1141- 1T1 FURNACE [ fl— " GENERATOR GRILLE _ ��f �� � �� s INFRARED HEATER LABORATORY.COCKS 31;47D " (,D twA K " MAKEUP AIR UNITOVEN POOL HEATER ROOM!SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 4 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 as of the detafs 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 ke�fin ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME'T\ , LICENSE# t5 a q SIGN��' MP® MGF❑ JP 0 JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME CGLv ,( a a v� I-G,��Ll,t yv 2 acADDRESS 10 . —,ri b- V__.t A J CITY S 1'1�� STATE ,�L f�- ZIP O S c c� t TEL CS C j 3\3" sc FAX CELL EMAIL -Rt'yt i'\- FAA FAA&Wti 12. L C./LC‘n ci -cE'CYi _ The Commonwealth of Massachusetts } * Al Department of Industrial Accidents s18o- f 1 Congress Street,Suite 100 5. Sitilar-, ' =` ;4 Boston,MA 02114-2017 wwwmagov/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): C (_A, P Address: ` CAQS:. r22! m old j City/State/Zip: S -e Z ,aMf'\ Phone#: of) ) , l 7-4 5 '�S Are you an errz�loyer?Check the appropriate box; Type of project(required): -- -- —------- I.n I am a employer with LI .employees(fun and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any.capacity.[No workers'comp.insurance required.) 9. ❑Demolition 30 I am a homeowner doing all work myself[No workers'comp.insurance required.] 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E'Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These gab-coutradors have employees and have workers'comp.insurancat 13. hoof repairs 6.0 We area corporation and its offices have exercised their right of exemption per MGL c. 14.❑Other 152,11(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. tCont actors that check this box must attached an additional shed showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they taut 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: C-t-- • t.! cT t 1 -‘ S _ Policy#or Self-ins.Lic.#: C S M P "�'J Cl I Expiration Date: ID, 1.(f) g-d 2�) Job Site Address: '),,<v C` h Rol City/State/Zip: V A. 12-rl't¢rlt._1 ,M, Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). b Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable 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 certify un • aloes o f p I•rby that the information provided above is true and correct Sitmature: Date: 0 Phone#• S 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#: