Loading...
HomeMy WebLinkAboutBLDG-26-641 ate-- MASSACHUSETTS UNIFORM APPLICATION FOR A PERM TO PERFORM GAS FITTING WORK ` CITY _ DATE2�',r PERMIT# JOBSITE ADDRESS G 3 c (,./i/P4 �O Ia.)) OWNER'S NAME 1� -_e__4 _ GOWNER ADDRESS TEL TYPE OR n FAX�� PRINT OCCUPANCY TYPE COMMERCIAL 51 A— r:EDUCATIONAL ❑ RESIDENTIAL 0 CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT 0 PLANS SUBMITTED:YES❑ NOtr APPLIANCES 2 FLOORS-r 5SM 1 2 3 1 5 6 7 8 9 _ 10 11 _ 12 13 1' BOILER BOOSTER CONVERSION BURNER _ COOK STOVE - DIRECT VENT HEATER - DRYER _ FIREPLACE I FRYOLATOR FURNACE - GENERATOR GRILLE _J INFRARED HEATER - LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVEIJTED ROOM HEATER - WATER HEATER (� /� " !' !?`. yj�? OTHER ,Q opc G LN / -�� I have a current liability insurance policy or its substantial equivalent COVERAGEINSURANCE nt which meets the requirements of MGL,Ch.142 YES k0 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 OWtdEP.OR AGENT CHECK ONE ONLY: OWNER 0 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 \ e a 41 ' Massachusetts State Plumbing Code and Chapter 142 of the 3enl Laws. /Ci/_q/ - A---_ PLUMBER-GASFITTER NAME Al i l^-€2 •w3 0 LICENSE# SIGNATURE MP❑ MGF❑ JP�[8 JGF LPGI 0 CORPORATION❑# P GOP PARTNERSHIP 0# LLC 0# COMPANY NAME Alt (`i( �,'�" ADDRESS 37`f.v7 6-/J? CITY/ -7 q n /, /S STATE- ZIP_,‘7 Z ,;; 4/ TEL 1?Y VO `)/Z/Z FAX CELL EMAIL /Ic !'•. 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 < � ne c,ummunweunn uj rviussucnusetts Department of Industrial Accidents f,, _L„ Office of Investigations WIN Lafayette City Center • '•— 2 Avenue de Lafayette, Boston,MA 02111-1750 �; www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 'Mate? r 1 447 Address: (-a-7 Alf-en City/State/Zip:It n ^ ` s Phone #: T� '{ l d I Z 2— Are ou an employer? Check the appropriate box: contractor and I Type of project(required): 1. 4. I am a I am a employer with ❑ general em oyees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.i 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 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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 contractors must submit a new affidavit indicating such. tContractors 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. Lie. #: fr('L 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 Envestigations of the DIA for insurance coverage verification. i do hereby certify under the pains and penalties of perjury that the information provided ab ve is e and correct Signature: JZ Date: 5— f' 7 G ?hone 7 7 ( q70 Z 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 2❑Building Department 31:City/Town Clerk 4.12 Electrical Inspector 5alumbing Inspector 6.DOther Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address" the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents. Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE ray 14171 11'7_?Ida COMMO1 WEALTH OF MASSACHUSETTS Division of Occupational Licensure I Board of State Examiners of Plumbers and 4 • Gas Fitters 1 Plumbing Journeyman Michael McBride 37 FRANKLIN AVENUE.HYANNIS. Massachusetts.02601 I EXPIRATION LICENSE NUMBER , 5/1/2028 19681-PL-J f i MASS.GOV/UPL . ..� • • ACCORC1 CERTIFICATE OF LIABILITY INSURANCE DATE(MINDD/ AE(MINDD/ 05/14/2024 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 Christian Barber,CIC The Oceanside Insurance Group IPHO AiC,Na Exti: (5118)7754)5°° I tom,Nq: (508)790-7955 E-MAIL ADDRESS: 52 West Main Street INSURERS)AFFORDING COVERAGE NAIC a Hyannis MA 02601 NSURER A: Mapfre Insurance CO. 23876 INSURED INSURER B: Twin City Fire Insurance Company 29459 Michael McBride DBA McBride Plumbing&Heating INSURER C 37 Franklin Ave INSURER D: INSURER E Hyannis MA 02601 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2421210204 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 ADDLSUeII POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE Rap WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDA'YYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2.000.000 DAMAGETO RENTED CLAIMS-MADE OCCUR PREMISES(Ea banner.) $ 1°°'" MED EXP(An,one person) 8 5,000 A 8008030010163 11/05/2023 11/05/2024 PERSONAL SADV INJURY $2900,000 GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $4,000,000 X POLICY❑ECT LOC PRODUCTS-COMP/OP AGG $"M'OD° OTHER'. XLEAD S AUTOMOBILE 11l18LLITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) $ _AUTOS ONLY _AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY _AUTOS ONLY (Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I I RETENTION$ $ WORKERS COMPENSATION >4PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE N/A OBWECAP9LEV 01/26/2024 01/26/2025 E L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) EL.DISEASE-EA EMPLOYEE $ EOO,WO If Yes.describe Aber DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ DESCRIPTOR OF OPERATORS I 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 Imitations and endorsement of the policy.Nothing contained in the certificate of insurance shaft be deemed to have altered,waived,or extended the coverage provided by the policy provisions.This certificate is issued as a matter of infonnatbn only and confers no rights upon the certificate holder.This is to certify that the policies of insurance listed have been issued to the insured named above. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main St AUTHORIZED REPRESENTATIVE Hyannis MA 02601 ©1988-2015 ACORD CORPORATION.All rights reserved.