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HomeMy WebLinkAboutBLDG-21-004229 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r1 C' CITY YARMOUTH MA DATE January 29,2021 PERMIT# BLDG-21-004229 fi- JOBSITE ADDRESS 52 CAPT YORK RD OWNER'S NAME LAWLESS JOHN J G OWNER ADDRESS LAWLESS J A POWERS J R&J M 43 GLENMONT ROAD BRIGHTON MA 02135 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 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 Andrew Leighton LICENSE# 16130 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: ANDREW R LEIGHTON ADDRESS. 20 Brewster Rd, CITY W Yarmouth STATE MA ZIP 026735706 TEL FAX CELL EMAIL halloilcompany(a)gmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No Ok- crs /12.112, THIS APPLICATION SERVES AS THE PERMIT 0 FEE: $ PERMIT# PLAN REVIEW NOTES �' MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FCn7NG WORK - ---7.----,Lv:j: CITY IA1-tc71t np VMA DATE PERMIT# . 1-D6-di ad ix r JOBSITE ADDRESS 5� C 4r-t_ o►a K •OWNER'S NAME -•-N v C,C�zs-en S OWNER ADDRESS ' ' ' ' TEL SYI--,.3> rj3y` FAX • TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL I/ PRINT CLEARLY NEW: 7-RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO V APPLIANCES'I FLOORS BSM 1 2 3 4 5 8 7 8 9 10 11 12 13 14 BOILER — BOOSTER • . CONVERSION BURNER COOK STOVE - • DIRECT VENT HEATER _ DRYER _ FIREPLACE • - - r _ FRYOLATOR - .. I ... - - FURNACE . 1 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 • _ OTHER • INSURANCE COVERAGE I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL..Ch.142 YES :✓NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL= LIABILITY INSURANCE POLICY V 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 : OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the delsls end information I have V� orentered Issued r this applip6on are and or my knowledge and that all plumbing want and Inam rw performed under tlatio Massachusetts State Plumbing Code and Chapter 142 of the General taws. be In A of the PLUMBER-GASFITTER NAME ANDREW LEIGHTON LICENSE# 16130-M 4' SIGNATURE MP • MGF JP JGF LPGI CORPORATION + # 3734C PARTNERSHIP # LLC # COMPANY NAME HALL OIL COMPANY INC. ADDRESS 435 RT 134 -- hallokompanyegmatcom CITY SOUTH DENNIS STATE MA ZIP 02r380 TEL r; : ,:VON - -- FAX 50$-394-3068 CELL EMAIL - L_ J • BLIILDlNG Dr:P,4 1 By Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s): 34363 MA Trade Self-Insurance Group Inc. Carrier Policy#: Policy Period PO Box 859222-9222 021004100192121 01/01/2021 to 01/01/2022 Braintree,MA 02185-0000 Information Page Renewal Policy FEIN:042149852 Carrier Prior Policy#: 021004100192120 Item 1: Named Insured and Address Agency Hall Oil Company Inc. RogersGray,Inc P.O.Box 1401 434 Route 134 South Dennis,MA 02660 South Dennis,MA 02660 Other Workplaces Not Shown Above: See Schedule of Operations Additional Named Insured: See Additional Named Insureds if Applicable Type of Business: Corporation Federal ID#: 042149852 Risk ID: 000048146 NCCI/Bureau#:34363 Unemployment ID#: File#:021004100192121 Item 2.Policy Period The policy period is from 12:01 AM on 01/01/2021 to 12:01AM on 01/01/2022 based on the insured's mailing address time zone. Item 3.Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $1,000,000.00 each accident Bodily Injury by Disease $1,000,000.00 policy limit Bodily Injury by Disease $1,000,000.00 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15),WC000313(04/84),WC000406(/),WC000414A(01/19),WC000422B(01/15), NOE(01/01),WC200102(01/14), WC200301(04/84),WC200302A(09/08),WC200303D(08/10),WC200306B(06/13),WC200405(06/01),WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules, Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit $549.00 $26,329.00 $26,329.00 $0.00 $0.00 Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by: gx,f Braintree MA 02185-0000 01-07-2021 Form#WC000001 C (Ed.) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 of 1