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HomeMy WebLinkAboutBLDG-25-608 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK zoml Ea xitlar CITY W./LAC 'I t41-+2iri uvT� MA DATE Air/ 3 1.1' PERMIT# &ber-Z�-&OO JOBSITE ADDRESS /5- /)-eiv✓eiZ. nn tr OWNER'S NAME ti(— L C C GOWNER ADDRESS U'J i T 6 '1 TEL co Zi4o y/O FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: / 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 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN ` t s o E I V E ®- i POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT NOV 0 3 2025 TEST UNIT HEATER BU►LD1Nu DL ARTMENT UNVENTED ROOM HEATER B,, - WATER HEATER OTHER INSURANCE COVERAGE � I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES t/NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY f 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ( PLUMBER-GASFITTER NAME WI r.m Al-fffr, ✓j LICENSE#/Z02/ SIGNATURE MP '"MGF JP JGF LPG' CORPORATION # PARTNERSHIP # LLC # COMPANY NAME: 3 H' St,,J r u G ADDRESS /3-3 4,4..)1 , /6" CITY tale jr ltiJA+tie��� STATE m4 ZIP 02 j-)6 TEL 5-0 ' '7G /0o1 FAX CELL 77Y. Y8 ' EMAIL 3 re7. -1,U E y /rJ/I- • �.7n, Department of Industrial Accidents ' Office of Investigations Lafayette City Center �,� ; 2 Avenue de Lafayette, Boston,MA 02111-1750 '' � www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Inform*tion /� Please Print Legibly Name (Business/Organization/Individual): l t(t A rrt i 1 0 6 4 ik .1(�u.1j i U. �u Address: iC3 (OU,Jry A)e41 City/State/Zip:lAi b y r UJ A w44-1 ,G14 Phone#: Sv E - 7 7 6 '- l a Are you an employer?Check the appropriate box: Type of project(required): 1.D I am a employer with 4. 0 I am a general contractor and I lnployees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.U I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.,' required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l 1.E 'Itlumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required,]+ c. 152,§1(4),and we have no employees. [No workers' 13.[rOther 7,4 comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. +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: Job 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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: l Date: IV iv 3 , E2 Z`f Phone#: 5-0 - ..- N O S- Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5alumbing Inspector 6.DOther Contact Person: Phone#: B&HSERV-01 MRAYMOND AC-ORE).- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `--� 10/28/2025 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 NAME: Almeida&Carlson Insurance Agency,Inc PHONE FAX 79 Davis Straits (A/C,No,Ext):(508)540-0161 I(NC,No):(508)457-7660 Falmouth,MA 02540 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:HARTFORD ACCID&IND CO 22357 INSURED INSURER B:The Fairway Agency William Heath DBA B&H Service Company INSURER C: 153 County Road INSURER D: West Wareham,MA 02576 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMBS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ _ 1,000,000 CLAIMS-MADE X OCCUR 08SBMBR7LPR 4/12/2025 4/12/2026 DAMMISES(AGE TOEa RENTED 1,000,000 PRE occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ X POLICY 2,000,000 PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 Business Liability General Aggre OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ONLY PROPERTY a�dentDAMAGE ) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB _CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY I STATUTE I EERH ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCC50050293072025A 6/1/2025 6/1/2026 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (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/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN of Yam ACCORDANCE WITH THE POLICY PROVISIONS. 1146 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AjA -. .SS E C u r-- S DO FO �M,I w4 . K�a*-,112 • ® III 1*EYY ," � 158RX M feet porr�' .' 600111048924Rw"Y 018 ' i`' DIVISION OF OCCUPATIONAL LICENSURE �i BOARD OF PLUMBERS AND GASFITTERB I ES THE- - NG LICENSE I MASTER`PLUMBER fILLIAM O HEATH JR 153 COUNTY RD WEST VYAREHAM,MA 02576-1508 r 12021 12�26 607257 I LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER C® •` . •FLt ' . 1 DIVISION OF OCCUPATIONAL LICENSURE BOARD OF II PLUMBERS AND GASFITTERS , DYING LICENSE I." .y(' ' 1-PLUMBER .£ M O IA,TI*JR - #COUNTY I ' 11�/ARAM,MA 02576-1508 } 1 9 ,26 1 606�116 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER