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HomeMy WebLinkAboutBLDG-21-001364 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �' CITY YARMOUTH MA DATE September 16,202 PERMIT# BLDG-21-001364 JOBSITE ADDRESS 21 BERWICK RD OWNER'S NAME SAINT LOUIS ANDRE A CO TRS G OWNER ADDRESS SAINT LOUIS LISE CO TRS 18 DURHAM RD LONGMEADOW MA 01106 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ID 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 1 BOOSTER CONVERSION BURNER COOK STOVE 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 r 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 El 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 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: COASTAL MECHANICAL ADDRESS. 21 L Fruean Ave, CITY WAREHAM STATE MA ZIP 025711324 TEL FAX CELL EMAIL lisa(a)coastalphc.com r 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 _y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w -� / 11/�I Y CITY West Yarmouth MA DATE 09/14/2020 ®PERMIT# i .. JOBSITE ADDRESS 21 Berwick Road OWNER'S NAME Lisa Saint Louis GOWNER ADDRESS 18 Durham Road-Longmeadow,MA 01106 TEL 1FAX TYPPIE OR OCCUPANCY TYPE COMMERCIAL 2° EDUCATIONAL Li RESIDENTIAL Li PR CLEARLY NEW: RENOVATION:® REPLACEMENT:Li PLANS SUBMITTED: YES 0 NO APPLIANCES 1 FLOORS—• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 ;1 �i BOOSTER l - 11__..... . 111111111 CONVERSION BURNER j I 1 COOK STOVE iIIIgnign, RR n DIRECT VENT HEATER , i DRYER FIREPLACE1 I FRYOLATOR 1 1 1 FURNACE GENERATOR GRILLE ! 'R, iiiii INFRARED HEATER j )i �',� �, LABORATORY s I 1 RR _ MAKEUP AIR UNIT O it , , lirmuli 1111111. R ginn ROOM I SPACE HEATER j UR ',WI I I ROOF TOP UNIT 1 TEST UNIT HEATER kIIII1IIIEU!I UNVENTED ROOM HEATER i 111.1111111 WATER HEATER _ li- IIIIFIIIIIFIIIIIJIIIINIIIIIIIIFIIIIIIIHIIIIIIIIIFIIIIIIIIIIIFIIIIIFIIIIIII �?! �. - - 111111111111111111111111111111111111HIMI11111111.11.111111111Will111111111.1111111111111111111111 IIMIIIIIINIIIIMIIMIIIIIMIIIIIIIIIIIIIIIII I i W INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO LJ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY D 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 Li AGENT I.1 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 Tro�r Gilbert LICENSE# 13573 /f IGNATURE MP MGF I___ JP Li JGF 0 LPGI CORPORATION®# j PARTNERSHIP Litt » J LLC L# 4350_ . COMPANY NAME:.Coastal Mechanical ADDRESS 21 L Fruean Ave CITY South Yarmouth STATE MAJ ZIP 02664 1,TEL 508-737 8747 0»»» FAX J CELL 508-850-6955 EMAIL lisaaa coastalphc.com • • The Commonwealth of Massachusetts "'-`'= Department of Industrial Accidents • 1 Congress Street,Suite 100 • %t if Boston,MA 02114-2017 www.mass.gov/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):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 of project(required): l.[ l am a employer with employees(full and/or part-time).* 7. 1ew construction 2.❑I am a sole proprietor or partnership and have no employees working forme in 8. tRemodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 9. ❑Demolition 10❑Building addition 4.0 I 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 arc sole 11, lectrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.1:1 f am a general contractor and I have hired the sub-contractors listed on the attached sheet, 13. Roof repairs These sub-contractors have employees and have workers'comp.insurancc.1 p 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other HVAC 152,§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 their workers'compensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such. teontraclors 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: AIM Mutual • Policy#or Self-ins.Lic.#: WMZ80080074082020A Expiration Date: 01/04/2021 Job Site Address: , 21 Berwick Road City/State/Zip: West Yarmouth, MA 02673 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,b25A 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 mid penalties of perjury that the information provided above is true and correct. Signature: 9am44-/t.%e& Date: 09/14/2020 Phone#: 508-737-8747 3. 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): I.Board of Health 2.Building Department 1 City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:. Phone#i • Client#:764315 2COASTALPLI ACORD DATE(MMIDD/YYYI)CERTIFICATE OF LIABILITY INSURANCE 01/09/2020 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 Dowling&O'Neil Insurance Agy ENO' (A/c,No): ADDRESS: P.O.Box 1990 Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIL 8 INSURER A: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 INSURER D: 299 Whites Path 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. LTR TYPE OF INSURANCE ASRL yUBR POLICY NUMBER SMM/ODY/YYYTU PMMO//DDD/YYYTY) LIMITS A X COMMERCIAL GENERAL LIABILITY MKLVIPBC000737 01/04/2020 01/04/2021 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR PREMISES(Ea s nce) $100,000 X BI/PD Ded:5,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO- POLICY X ECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER $ C AUTOMOBILE LIABILITY 5906835 01/04/2020 01/04/2021 (EoaBca1. DSINGLEUMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ _ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) $ A UMBRELLA UAB _ OCCUR MKLVIEUL102215 01/04/2020 01/04/2021 EACH OCCURRENCE $1,000,000 X EXCESS LIAB X CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION$ $ B WORKERS COMPENSATION WMZ80080074082020A 01/04/2020 01/04/2021 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N EL EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? N N/A (Mandatory In NH) EL DISEASE-EA EMPLOYEE $1,000,000 if 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 If more 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(2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #52516441M251588 LS1 • • >r"_1ky OMMONW 41 TH OF F $ ..' a • 1 a - - • • AL PLUMBER" ' GASF bt"I aF .pli ..... ►, FOLLOWING S..r Y ut'., •*1' . 41-3---•r•' .- -Ee; , •./ C J GILBERT `* O T ! AND HEA `` f P. c j • w I�,MA'02ls , , •,, 1- I ►, 4350 ..,c 01, . . . 856115 LICENSE ]UMBER EXPIRATIOMN DATE SERIAL NUMBER iti • • Li:i 1 V1 • i, 3cl l- fir .,tia 3 { 71 • r DIVISION OF PROFESSIONAL LICENSURE PLUMBS ' `* I ASF ; t`" j ISSUEFOLLOWING 4'1' •? 3'' I IE EY , E7. s +sb:i \�" { • JGILBERT /'\� I WARE 0 t / r _� . ,a 25383 - ' 0 01/20. ,.•. . ` 831568 • Z , LICEM;SG NUM DER EXPIRA)IU".DATcr SERIAL NUtiBER ; • 1 ------ CONTROL#..J01462784 CONTROL# 1JO143828ti IMPORTANT IMPORTANT '� � ,Is Inaccun31te;or ;. If.yo need r license Is lost,damaged or destroyed;Is Inaccurate;or your yyca is lost,damaged we s�masa.gov/ for 1 needs to be corrected,visit our web site at mass.grnr/dpl for Ifto be corrected thedoper malting of your Renewal instructions to ensure the proper mailing of your Renewal instructions to ensurother•c er ce. Application and any other correspondence. Application and any Generalts Laws and ' This license is subject to Massachusetts General Laws and ye is subject to Massvilege�and canr tip lent or this I, and cannot be lent or This regulations.Your license Is a privilege, reputations.Your ilcenseor entity under y eaalty-law am assigned to any person or entity under penalty of law.Keep thisass r►ed to any person as rebsusd P license on your person or posted as required by law and/or license your person or posted re$ulatior►s. regulations.