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HomeMy WebLinkAboutBLDG-21-003766 Y- l MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 9 CITY YARMOUTH MA DATE January 07,2021 PERMIT# BLDG-21-003766 JOBSITE ADDRESS 68 CAPT WRIGHT RD OWNER'S NAME BORDUN BONITA G OWNER ADDRESS BORDUN JASON W 68 CAPT WRIGHT RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 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 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: 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 Troy Gilbert LICENSE# 13573 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: COASTAL MECHANICAL ADDRESS. 21 L Fruean Ave, CITY WAREHAM STATE MA ZIP 025711324 TEL FAX CELL EMAIL lisa(a,coastalphc.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El El FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ci s a f CITY South Yarmouth MA DATE 12/30/2020 PERMIT# �(,66-ai t,�JJ7 ''' JOBSITE ADDRESS 68 Captain Wright Road OWNER'S NAME Bonita and Jason Bordun GOWNER ADDRESS same s TEL 'FAX J TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL jj RESIDENTIAL�_t PRINT CLEARLY NEW:LI RENOVATION: .._,.. REPLACEMENT: ..', PLANS SUBMITTED: YES__,I_ NO APPLIANCES Z FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER . CONVERSION BURNER - F 7 COOK STOVE ._.` _,_.,; 1.��...�� DIRECT VENT HEATER DRYER I FIREPLACE I f.',11 1 1 I1II II hI I Bii all FRYOLATOR FURNACE untimirmilsowwwinimirwwwwww GENERATOR IIIIIIIIIIIIIIIIIIIMIIIII OM MI 111111111111.11111M111111111111111111111111111111111111111111 GRILLE ill..---11 INFRARED HEATER I I R 1 1 I. LABORATORY COCKS R i i .3, f� i MAKEUP AIR UNIT 1 I Ik`I _ OVEN I 1W I I POOL HEATER i. 1 �! ? �,1JIS ` ROOM/SPACE HEATER w"G 0.I' ROOF TOP UNITolio nit 1. „ _ II altionlin UNIT HEATER IonI I II UNVENTED ROOM HEATER Mil=WATER HEATER___ I WinOn1111111111. OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI NO al I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Li BOND Li 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 r--1 AGENT U,. 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. 29g/L r PLUMBER-GASFITTER NAME 1 Troy Gilbert LICENSE# 13573 IGNATURE MP D MGF JP 0 JGF LPG' CORPORATION U# PARTNERSHIP El#E1:7-1 LLC #F4350 COMPANY NAME:[Coastal Mechanical I ADDRESS 21L Fruean Ave CITY I South Yarmouth STATE MA `ZIP 102664tTEL 508-737-8747 FAX I CELL 508-850-6955 EMAIL lisa@coastalphc.com Client#:764315 2COASTALPLI ATE(MMroD/WYI� 'ACORD,. CERTIFICATE OF LIABILITY INSURANCE D01/09/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: The Hilb Group of N.E.dba PHONE 508 775-1620 FAX 5087781218 Ext): (A/C,No): Dowling&O'Neil Insurance Agy - E-MAIL P.O.Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Evanston Insurance Company 35378 INSURED INSURER B:A.I.M.Mutual Insurance Company 33758 Coastal Plumbing&Heating LLC INSURER C:Safety Insurance Company 39454 Dba Coastal Mechanical 299 Whites Path INSURERD: South Yarmouth,MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD_ POLICY NUMBER _IMMIDDIYYYY)JMM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY MKLVIPBC000737 01/04/2020 01/04/2021 EEAACCHp�OECCpURRREENCE $1,000,000 CLAIMS-MADE X OCCUR PREMISES(Ea oacu�nence) $100,000 X Bl/PD Ded:5,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 GEM_AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 RO- POLICY X JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: C AUTOMOBILE LIABILITY 5906835 01/04/2020 01/04/2021 Fang Ezz INGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ _ AUTOS OWNEDSCHEDULED BODILY INJURY(Per accident) $ ONLY X AUTOS X WIRED ONLY XNON-OWNED PROPERTY DAMAGE _ AUTOS ONLY (Per accident) A UMBRELLA LIAB OCCUR MKLVIEULI02215 01/04/2020 01/04/2021 EACH OCCURRENCE $1,000,000 X EXCESS UAB X CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION$ $ B WORKERS COMPENSATION WMZ80080074082020A 01/04/2020 01/04/2021 X PER OTH- ERAND EMPLOYERS'LIABILITY STATUTE OFFICERIMEMEEXCLUDE ?PROPRIETOR/PARTNER/EXECUTIVE YN NIA N EL EACH ACCIDENT $1,000,000 (Mandatory In NH) EL DISEASE-EA EMPLOYEE $1,000,000 E yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached Emma space is required) insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 134 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988 2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of I The ACORD name and logo are registered marks of ACORD #52516441M251588 LS1 The Commonwealth of Massachusetts lr Department of ludustrial Accidents • 47 \ I Congress Street,Suite 100 Boston,MA 02114-2017 www tnass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. . TO BE PILED WITH THE PERMITTING AUTHORITY. Anpficant Information Please Print Leaiblv Name(Business/Organization/Individual):Coastal Mechanical Address: 21 L Fruean Ave City/State/Zip:South Yarmouth, MA 02664 Phone#: 508-737-8747 Are you an employer?Check the appropriate box: Type o project(required): l.�l ate a employer with employees(bill and/or pan-tune).* 7. ew construction 2.0 I em a sok proprietor or partnership nod have no employees working for me in 8. [ c.emodeling any capacity.(No workers'comp.ittsurmtee required.) 3.0 I am a homeowner doing all work myself.(No workers'comp.insurance required.) 9. ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property, t will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. lectrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5,0 I sin a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-connectors have employees end have workers'comp.Insmancai 6.0 We are a corporation13.[�Roof repairs and its officers have exorcism' right of exemption 14.[ Other H�/AC mption per NHL c. 152,f 1(4),and we have no employees.(No workers'comp.insurance required.) *Any applicant that checks box HI 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. tContraetors that check this box must attached en additional sheet showing the name of the sub-contractors and state whether or not those entitles have employees. Item sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that I providing workers'compensation Insurance for my employees. Below Is the policy and job site biorma/lon. Insurance Company Name: AIM Mutual Policy II or Self ins.Lio.#: WMZ80080074082020A Expiration Date: 01/04/2021 Job Site Address: ' 68 Captain Wright Road City/State/Zip: South Yarmouth, MA 02664 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date), • Failure to secure coverage as required under MOL 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 flee 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 under the pains and penalties of perjury That the information provided above Is true and correct. Signature: G �� Date: 12/30/2020 i'hone#: 50_8-737-8747 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 I.Board of Health 2,Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other } Contact Person:. Phone lit • 5 a, • • • • • OOMMONWal-TH OF M > O S PLUMBEI GASF' 'tc3aWS' iSS T FOLLOWING l is y v. . TE EP%M M �C IAZ \\ . IP J GILBERT 's • `'r 'tY ,��i„ Off4.r 0 T L�;>p'. 6110 AND HEAT_ �p �,,A 39 STI N S RE T H_ k `r. • R HAM,MA'0257 '•-40'" ': _ i,1' '._'''�;i :'s �r: ��� a �fi'�'� "` 43501,00 0 i01.I) ;:fix 856115. '° LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER ' il • DIVISION OF PROFESSIONAL LICENSURE I PLUMBEASFE1':;. •X'Pi I ,VP,. �� . ISSUE �'0'OLLOWING's( •'le :b�,},�� rJbs .k.kto EYNlisrAU V j E ::•s +f , JJ�� y J GILBERT ' $' .1 ,,1 ,� ' +,' I g xg��y@at" T �frc 1 r V# WAREN tit 0 57 24trA„ . ,�/ ./ , r.,,,.$>kv of y��h� a¢ a; '• ._.'s.'1„"tE a 25313 9 3 0�5%01120 8.31568 „> . • K3 "". I LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER '1 r . I CONTROL#..J 014 6 2 7 H 4rCOHmo * J0143828 \ IMPORTANT ' IMPORTANT js inaccurate;°C ed or destroyed: ov/dpl for If.your license Is lost,damaged or destroyed;Is inaccurate;or yf your license is lost,damag of our Renewal needs to be corrected,visit our web site at mass.gov/dpl for needs to he corrected,nisi your mailing f our Renewal Instructions to ensure the proper mailing of your Renewal Instructions to ensurother corpresporidence. Application and any other correspondence. Application and any to j�lassachusetts General Laws and Ttris yjcense is subJ r chose,and cannot w lent orthis This license is ur lisubjectn to Massachusetts General Laws and natty of jaw•Keep regulations.Your license is a privilege,and cannot be lent or ulations.Your yicense is a p jaw and/or assigned to any person or entity under penalty of law.Keep this a g igned to a any Person°C a st as equjmd by license on your person or posted as required by law and/or license on y person or pos regulations. regulations.