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HomeMy WebLinkAboutBLDG-21-003921 MASSACHUSETT,§,UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK krt CITY YARMOUTH MA DATE January 15,2021 PERMIT# BLDG-21-003921 JOBSITE ADDRESS 481 BUCK ISLAND RD UNIT 17DC OWNERS NAME ARSENEAUX RICHARD T G OWNER ADDRESS ARSENEAUX SUSAN S 32 BETTYS PATH WEST YARMOUTH MA 02673 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 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 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 El 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 Thomas Coughlan LICENSE# 8529 SIGNATURE MP© MGF ❑ JP❑ JGF El LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: THOMAS J COUGHLAN ADDRESS. 48 HERITAGE DR, CITY WALPOLE STATE MA ZIP 020812240 TEL FAX CELL EMAIL r 4 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 _t- " CITY l t. SCC- -rft•�' MA DATE I 8' PERMIT#06-21 - 11 JOBSITE ADDRESS /Lvl R' Ci -��.(( 5-11202 Rd OWNER'S NAME A., `4oey GOWNER ADDRESS (J 11' TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL k PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO APPLIANCES 7 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 GENERATOR GRILLE _ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER R E (� �� ` ROOF TOP UNIT n + TEST UNIT HEATER JAN 1 3 2R. , jd UNVENTED ROOM HEATER i WATER HEATER YV� NG pFp°RTAA�. r OTHER INSURANCE COVERAGE 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 BELOW LIABILITY INSURANCE POLICY kr 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 ONLY: OWNER ❑ AGENT ❑ 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 pray re Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f ' �7 /1� 1 PLUMBER-GASFITTER NAME LICENSE# �J SIG AT J MP Pir MGF❑ JP"JGF❑ LPGI❑ CORPORATION [IV 4057 PARTNERSHIP El# LLC❑# COMPANY NAME fi 1 -7(i(,I r-`(— CW &"ADDRESS O (r Z /53 4 ....")(4.4Ve. CITY /144-AA. Litt, STATE /- ZIP A )? TEL 37S8 -'23 1-:bO l FAX CELL EMAIL C 2c it • �ON. �-�i� 8613 ���� 4�-j Deprzrtmefit of.IridustrlolAcemems X Congress Street,Suite 100 • = Boston,11 0211•f 201i `' • i-vww_niassgovh-ur Workers!Compensation Insurance Affidavit Builders/Contractors/Electricians/Plsrmbens. TO TIE FILED Van"Lti.1 PEIlMlrlING AU'LHO17,T1Y. Applicantlnformation Pease Print Legibly • Name(Business/Organization/Individual): Address: • City/Statc/Zip: Phone#: Areyou an employer?Cheek the appropriate bow Type of project(required): 1.[]Iama employer with employees(Full andlorpart-time).* 'J 111Tcwconstruction • 21•Iam a solo propriclor orpartnership and have no employ=working forme in B. D Remodeling • any capacity.[No workers'comp.insurance required_] 3❑Tsai a homeowncr doing all work- No workers'comp:insurance 9- ❑Demolition k- 4.❑I am ahom n cowncrandwillhehiringcontractorstoconductallworkamyprnparty.Iwill ID $u11diI]gaddition . ensue that all contractors citharhavaworl-es'compensation insurance or are solo 11.[[Electrical repairs or additions proprietors vtith no employees. • - . 12 Plumbing repairs or additions s I am a general conhaciorand I have hired the sob-contractors listed Bathe attached shot These sub-contractors have employees and hoc workars'comp.insurance.: 13_Q ROD frepairs • 6.0Vle arc a corporation and its officcrs hive cramiscd tiicirrightafcxrarption per v ur c. 14.Daher 152.§I(4),and we have no employees.No worEas'comp.insunuree required_] • • • • *Any applicaatthatcharh boat must also Ell out the setion belowshowingtheirworkers'compensation policy informatics. tFlomcownerswhosubmitthisafdavitindimbngtheyarcdoingallworkandthanhire'outsidecontractorsmustsubmitanewaf davit indicating such. tantractors that check this box must attachert an additional sheet showing the tame of the sub-contractors and stalewhcthcr or not those entities have mmployecs. rfthe sub-contractors have cmploycas,they must provide their workers'comp.policy mnnbar. I mrc rIIt traployer deaf is pravi ng1florkers'ronrpexrtdioa 6zrnrancefor trry erg3loyez.r. .23doer it-the pofry rnrdjab site rnfarmatron. Insurance Company Namc: • • Policy#or Sclf-ins.Lic.#: Expiration Date: • ]rob Site Address: • • . City/Scat /Zip: Attach a copy of the workers'compensation policy declaration page(sh owing the policy number and expiration date). Failure to secore coverage as required under MGL c.I52,§25A is a criminal violation punishable by a fine up to 1,500.00 and/or one-year imprisonment;a$Well as civil penalties in the form.of a STOP WORK ORDER and a fine of up to. SO.DD a day against the violator.A copy of this statement may be forwarded to the Office oflnvestigations of the DIA for insurance coverage verification. • I do hereby cif ander the pains rvrd pennlfier af,perjury that ilre infarmafian pravided above is tore turd eorrecG • SignaLur c: - Data: • Phone#: • Official use only. Do riot write in this mzq to h letr'1 3y city ar taltur off ciaL ' • Qfy or Town: Permii/License# . Issuing Authority(circle one): • . . • LBo grid ofHealth 2.Butiding-Deparfrnent3.CityfTownClerk 4.ElctricalInspector 6.Plumbing Inspector 6.Other Contact1'erson: Phone#: •