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HomeMy WebLinkAboutBLDG-23-003872 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK iit=; 7 CITY YARMOUTH MA DATE January 17,2023 PERMIT# BLDG-23-003872 .45 JOBSITE ADDRESS 43 DIANE AVE OWNER'S NAME Arthur Arsenault G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 El 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 Michael Mcbride LICENSE# 19681 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbrideta7amail.com j- 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 MASSACHUSE t I S UNIFORM APPLICATION FOR, /I/ZO ERMIT TO PERFORM GAS FITTING WORK ,t r,� �' CITY � �( /i/ l/ " 'l MA DATE ( 3 PERMIT# 23 ` 3I7 L JOBSITE ADDRESS y 3 6 i ll 1) Ap t Ave 'S NAME A.C 1 it //41 J^''fr&(4- G OWNER ADDRESS ii ' TEL •776"47°5 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL[. PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:123 PLANS SUBMITTED: YES 0 NOM APPLIANCES Z FLOORS-' RSH 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 R .i . POOL HEATER ' ROOM!SPACE HEATER ^" ROOF TOP UNIT J,113 13 TESUNIT e JILDI p'qk l i - UNIT HEATER G n UNVENTED ROOM HEATER - _ N►EN WATER HEATER V `�____ OTHER ESTIMATED VALUE OF WORK:liltt 1 I I I I I I t I I INSURANCE COVERAGE I have a current liability insurance policy or'its substantial equivalent which meets the requirements of MGL Ch.142 YES iyt NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Iv OTHER TYPE 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. CHECK ONE ONLY: OWNER 0 AGENT 0 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 Imowledge and that all plumbing work and installations performed under the permit issued for this application will be it compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t q/�I 0 N PLUMBER-GASFITTER NAME ,`rl C) I s k ! '! 1 C Aef e L LICENSE# SIGNATURE MP❑ MGF❑ JP JGF❑ LPGI❑ CORPORATION❑# R P PARTNERSHIP 0 U C❑# COMPANY NAME k)3c l do P 4.--Ai ADDRESS 7 rf,A k.11,ni Art CITY I 0 I) v I I STATE____ ZIP 0 7 6)0 / TEL )) W 6 CP 17 2 FAX CELL EMAIL 54tr)5 er. Mc8 r ►ce, vs IL.COr h s0 Ciay&.0 T• The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 ,i-�- www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WTTH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly • Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate bon. Type of project(required): L0 I am a employer with employees(fun and/or part-time).* 7. ❑New construction 2 fl I am a sole proprie tor orparmeaship and have no employees working for me in 8. ❑Remodeling . any.capacity.[No workers'comp.iasurmce required.] • 301 am a homeowner doing an work myself.[No workers'comp.insurance required.]t 9. El Demolition 4.0I am a bomeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensue that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions with IIO employees. 12.❑Plumbing repairs or additions 5.0 I am ageneral contractor and I have hired the sub-contractors listed on die attaehedsheet These sub-contractors have employes and have workers'comp.insurances 13.1pRoof repairs 6.0 We area corporation and its officers have exercised their right of exemption per MGL a 14_❑Other • 152,§1(4),and we haven employees.[No workers'comp.insuranceregnired.] °Any applicant that checks boa 1E1 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 tContractors that check this box rout attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees.lithe 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 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 certifr render the pains and penalties of perjury that the information provided above is true and correct Signature: Date: • Phone#: 1 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#: