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HomeMy WebLinkAboutBLDG-21-007320 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7 it CITY YARMOUTH MA DATE June 16,2021 PERMIT# BLDG-21-007320 ti JOBSITE ADDRESS 27 BLUEBERRY PATH VILLAGE OWNERS NAME donna potter G OWNER ADDRESS 27 BLUEBERRY PATH VILLAGE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 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 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 I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 Ryan White LICENSE# 16068 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: RYAN L WHITE ADDRESS. 19 SKIPPERS DR, CITY Harwich STATE MA ZIP 026453122 TEL FAX CELL EMAIL rwhite1011t gmail.com 0- 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 7 i1/4=r+� Y CITY 46rAoLe� MA DATECo 9" PERMIT J#� � Z � 2 ' �-�"' � 0 JOBSITE ADDRESS 2 7 e/ut'6'rr`l AlO u OWNER'S NAME I o�Y� GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:V PLANS SUBMITTED: YES❑ NO❑ _ 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 _ FRYOLATOR FURNACE 1 _ 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 have a current liability Insurance policy or its subst ntial equivalent which meets the requirements of MGL Ch.142 YES VNO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY W 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 ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that aft of the detats and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all piunbing work and installations performed under the permit issued for this application will be in compr with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, PLUMBER-GASFITTER NAME 124 ch LAA,� LICENSE# / o SIGNATURE MP�GF❑ JP❑ JGF El LPGI❑ CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME LL:IBC. \T T 4 ADDRESS PO .I( L( Z CITY 14,t1•�. STATE I ZIP v TEL S— TEL So 21 - 73 7 r- FAX CELL EMAIL g f .'k (B 1 I` 5 Ar n.`l r-e'^-n ,- • The Commonwealth of Massachusetts ► t i 1 Department oflndustrialAccidents I Congress Street,Suite 100 = � Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMIT-MG AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organizafion/Ineiividual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box. Type of project(required): LEI I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any.capacity.[No workers'comp.insurance required.) 3.o I am a homeowner doing all work myself.[No workers'comp.insurance t 9. Demolition❑ ' l 10[�Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole MD Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insutancat 13.0 Roof repairs 60 We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑Otter 152,f 1(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 then 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. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the 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: lob 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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 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 ! i Contact Person: Phone#: