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HomeMy WebLinkAboutBLDG-23-005544 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e CITY YARMOUTH MA DATE April 05,2023 PERMIT#r BLDG-23-005544 JOBSITE ADDRESS 1305 ROUTE 28 OWNER'S NAME U S REIF MARINE NANTUCKET FEE LLC G OWNER ADDRESS 134 ORANGE ST NANTUCKET MA 02554 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL V❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES 0 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 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 1 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITYD i BOND 0 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 'David McCrossin LICENSE# 21694 SIGNATURE MP 0 MGF❑JP❑ JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME IDAVE THE PLUMBER 'ADDRESS. P 0 Box 352, CITY (Dennis STATE MA ZIP 02639 TEL 5083983283 FAX 1 1 CELL 15083983283 1 EMAIL 1 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _� �` CITY S C r M o v+ MA DATE 2 PERMIT# US RE IF Mclr;n.e JOBSITE ADDRESS / 3 0 S /2- %� �S' OWNERS NAME 13L� d�R�� s N a 3 tUC6C�-� Fee LI . OWNER ADDRESS r, ��C L M OZ 5 O TEL Z2) -4 6j C.6 FAX, TYPE OR OCCUPANCY TYPE /v COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO D APPLIANCES-1 FLOORS- BEN 1 2 3 4 5 6 7 B 9 10 11 12 1; 1" j BOILER BOOSTER CONVERSION BURNER COOK STOVE • DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT I I 1 !z 1 f. POOL HEATER • ' �` _ ' ROOtvi!SPACE HEATER • 175 .i. ROOF •' UNIT - .BU �. RIM:NI UNIT HEATER By - — INVENTED ROOM HEATER ii WATER HEATER OTHER replace " as i ne under .04cK • e k to 4 e 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 tid 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 • ■liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '� _ J � N L 1 (tfzrL(y (, PLUMBER-GASFITTER NAME V Id r1CLro55:an LICENSE# z,i�c;y SIGNATURE MP❑ MGF❑ JP 154 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑#r LLC❑# COMPANY NAME 11�� e eIv+��er- ADDRESS x' 3 cz CITY P rT STATE Pt ZIP 02. l.o TEL TEL 6CD8-3a8 -3293 _ FAX CELL EMAIL 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 • • • • • •