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HomeMy WebLinkAboutBLDG-21-004816 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �'_ CITY YARMOUTH MA DATE February 25,2021 PERMIT# BLDG-21-004816 n JOBSITE ADDRESS 108 BERRY AVE OWNER'S NAME SCHATZ KATHLEEN G OWNER ADDRESS 108 BERRY AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El 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 DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 1 ROOM I 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 0 OTHER OF INDEMNITY ID 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 0 LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: COASTAL MECHANICAL ADDRESS. 21 L Fruean Ave, CITY WAREHAM STATE MA ZIP 025711324 TEL FAX CELL EMAIL lisal coastalphc.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ El FEE:$ PERMIT# PLAN REVIEW NOTES `"- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' _�( � s' CITY West Yarmouth MA DATE 02/23/2021 PERMIT# 13i. DC9 —Zr-oay (to JOBSITE ADDRESS 108 Berry Ave _ . _ _ __ .„OWNERS NAME Mary Ann Miller 1 GOWNER ADDRESS 23 Otis Lane Bay Shore,NY 11706 1 TEL FAX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL, PRINT CLEARLY NEW: RENOVATION:, REPLACEMENT:® PLANS SUBMITTED: YES LI NO .., APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 I 7 8 9 10 11 12 13 14 BOILER 1. .L _� I . I Li I ,. I i I It 1 BOOSTER 1 CONVERSION BURNERi . 1 COOK STOVE I l ._ I DIRECT VENT HEATER -.` i L DRYER ..�' ., .. ...ti ii —i FIREPLACE i I I ir FRYOLATOR 'L. i ... :LEI 1 L L 1 FURNACE GENERATOR .-. .._._ Ii. . —11 GRILLE 1 tL... I_ . ....__.' I I_. II .1 INFRARED HEATER LABORATORY COCKS [ _ . MAKEUP AIR UNIT i. II t 1 OVEN 1 POOL HEATER .,. ROOM/SPACE HEATER 1 I_ J —I _, — I . .1. __ ,111 i ROOF TOP UNIT I I I h _�I I ._..� � w __...IL___{ TEST I II ' ._ t I .I _ _11 t.. (. I_ ... UNIT HEATER 1.1i II a of 1 UNVENTED ROOM HEATER � _m.., �I __. _. __._.. tlT_,..._o.l( ..,-. -.. _ ®. _... . ... i WATER HEATER OTHER €i . _.__ .. ,. I I_ I. „ _=L . . ` _ , J 1— INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1 i 1 OTHER TYPE INDEMNITY LI 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 Lj AGENT Li 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 /j SIGNATURE MP Li MGF JP® JGF® LPGI J CORPORATION®# PARTNERSHIP # LLC[]# 4350 J COMPANY NAME: Coastal Mechanical I ADDRESS 21 L Fruean Ave CITY South Yarmouth STATE MA I ZIP 02664 'TEL 508-737-8747 FAX CELL 508-850-6955 EMAIL lisa@coastalphc.com The Commonwealth of Massachusetts 1' =!I Department of Industrial Accidents ' — ' 1 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 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 ofproject(required): t.Efl an a employer with 30 employees(full andfor part-time).* 7. ew construction 2.0 1 am a sole proprietor or partnership and have no employees working forme in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]+ 9. CI Demolition 4.0 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Eluilding addition ensure that all contractors either have workers'compensation insurance or are sole II.lUtlectrical repairs or additions proprietors with no employees. 12. 1Plumbing repairs or additions 5.0 I 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.insurance.: 6.0 We e a corporation and its officers have exercised their right of exemption per MGL c. 14.VOther Hvac ate I52,*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. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContracrers 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. 1 am an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: Hartford Finacial Services Group Policy#or Self-ins.Lic.#: O8WECAJ7RT4 Expiration Date: 12/31/2021 Job Site Address: 108 Berry Ave 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,*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 under the pains' andl penalties of perjury that the information provided above is true and correct. Signature: yB' Date: 02/23/2021 Phone#: 508-737-8747 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.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A DATE(MMIDD/Y YY) CERTIFICATE OF LIABILITY INSURANCE 01/06/2021 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Tina Reeves NAME: Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX (A/C,No,Ext): (A/C,No): 973 lyannough Road E-MAIL treeves@doins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: The Hartford Financial Services Group 91 INSURED INSURER B: Coastal Plumbing&Heating LLC INSURER C: Dba Coastal Mechanical INSURER D: 21L Fruean Way INSURER E: South Yarmouth MA 02664 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 INSD WVD POLICY NUMBER (MM/DDIYYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ 10,000 A O8SBAAJ7RXH 12/31/2020 12/31/2021 PERSONAL aADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X jRE8: LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ - OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A - EXCESS LIAB CLAIMS-MADE 08SBAAJ7RXH 12/31/2020 12/31/2021 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION X STATUTE EOTH AND EMPLOYERS'LIABILITY Y/N 1 A ANY PROPRIETOR/PARTNER/EXECUTIVE N NIA 08WECAJ7RT4 12/31/2020 12/31/2021 E.L.EACH ACCIDENT $ , , OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I 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 thecoverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Town Hall;1146 Route 134 AUTHORIZED REPRESENTATIVE I South Yarmouth MA 02664 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • • • OMMONW tTH OF M',F, ‘k.WISETt, ':.54 4DIVISION OF PROFESSIONAL LICENSURE PLUMBERlx•atiD'GASF k "`¢`� J.S9.'wn$•' Ptil IS FOLLOWING Ia 1BE , °-k. ,°-k.:.!,F-.,-,,:'- t 4 n tS-r '' J GILBERT i la e,it ,;,, . O. 7q�.: , p. IG ANp HEAT a�s ,. L'1: 39 STA ,1;�NSVR T :.. „•0•4,"` %> . 1 .ram _,', W R IAM,MA'025f ''° n :'X it'pi'tii: ::;7` I ,,I-A71 s.'.:,44380 II,. ti° 0-/012 0, 2 3 . 856118 ' LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER ''f.til .,,M 0 LM0 /L'_;,;_ 0 u' .11 u`'> DIVISION OF PROFESSIONAL LICENSURE &fPLUMBEi iiiktASFI I • u,r t ' , 1 ro,,,, ISSE FOLOWNGC E A % '_„,.. it 3,.,4!J GILBERT ''' .:/ ,': i •, e 1y r/ . i • ATIO111,. T• ,`;"` , WAREF 057�;1 o, ',~+ i; •tea .�li . , . z. • • r .. 'iw•., ,t,K :7 3+•}.<;n 9'., F/1,,'S•g. ws. 25383 s 05/01/202 831568 ; • LICENSE NUMBER EXPIRATION DATE SERIALNUMBER _ I CO NTROL#•.J O 14 6 2 7 8 4 CONTROL# 'J 014 3 8 2 8 `` r IMPORTANT IMPORTANT ed;is Inaccurate;or damaged or destroy ov/dpt for If your license Is lost,damaged or destroyed;is Inaccurate;or If your license is lost, visit our web site at Mass.gov/dpt to be corresuee ire proper mailing of your Renewal needs to be corrected,visit our web site at your Renewal for Instructions to en port instructions to ensure the proper mailing of Renewal other•correspo Application and any other correspondence. Application and any This licenseono subject to Massachu et,:ndece ral be l an prthis This license is subject to Massachusetts General Laws andrivileg enalty of the regulations.Your license is a privilege,and cannot be lent or regulations.Your license is a P required by law and/or assigned to yourany person or posted under penalty of law. d orep this assigned to any person or entity dpas License on person as required by law and/or license on your Person or pot regulations. i regulations•