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Home My WebLink AboutBLDG-21-006999 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 03,2021 PERMIT# BLDG-21-006999 JOBSITE ADDRESS 21 RHINE RD OWNER'S NAME DESROCHES NERVE G OWNER ADDRESS 21 RHINE RD YARMOUTH PORT MA 02675-2464 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 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 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/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 El 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❑ MGF El JP El JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP El# LLC ❑# COMPANY NAME: DAVE THE PLUMBER ADDRESS, P 0 Box 352, CITY Dennis STATE MA ZIP 02639 TEL 5083983283 FAX CELL 5083983283 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 _'- PERMIT MASSACHUSE i t S UNIFORM APPUCATION FOR A PEIT TO PERFORM GAS H i i ING WORK . r=Lf. _ __'f_' CITY , ' a r r-r v A h MA DATE ( PERMIT# aur - Z l -oo bcl`I`J JOBSITE ADDRESS• 2- i k In ; teNe t"tt J OWNER'S 1-t e r ve 1 c . GOWNERADORESS ! N1 TYPE OR OCCUPANCY TYPE COMMERCIAL s ' 1 PRINT EDUCATIONAL RES@Ei�ITIAL `� "'�: - cra7- ART Y NEW:[] REIOVATION:[1 REJ'LACEMENT: - _ PLANS SUBMITTED: YES Ei NO Li APPLIANCES Z FLOORS-4 B5M 1 2 3 4 5 5 7 - 8 9 10 11 12 13 14 BOILER M. _ ri I ��• BOOSTER . i ' ,- - �� CONVERSION BURNER - z =�I now i mmi . COOK STOVE. • _ _ �� E. mum . . . DIRECT VENT HEATER :� f ; Tara. = _ � —IMM. FIREPLACE �� - - � � - FRYOLATOR `' '.�� ' ' ' _ _ FURNACE - - i - - I• -� _ - GENERATOR ' ^-_ ;�' Ii 1 i GRILLE _ _ _ -_- — = i — E • INFRARED HEATER _ _ LABORATORY COCKS : _ - It j MAKEUP AR UNIT MW:: �— � cif r _ . ,OVEN . MEW ,. ; i ; I ' 111_101.11MM . POOL HEATER ft—i ;WWWIMM ROOFROOM iSF'ACE HEATER • � _-iitiWW. &Orloff - � EM i ; •�� y TOP UNIT r. UNIT HEATER I F i s . UNjIENTED ROOM HEATER W - ' - WATER HEATER • = ! _ ; ; . OTI-Ei 1 if ; MO . 111111M• ; 1- 11111._ I____-_MMI • INSURANCE COVERAGE . I have a current Irabfty insurance poky or Its substantial equivalent*Inch mks the requirements of MGL Ch. 142 YES rA NO LI • I IF YOU CHECKED YES,PLEASE INDICATE-THE TYPE OF COVERAGE BY CHECKING MIE APPROPRIATE TE 3OX R, T OW - . LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Li. BOND Q. OWNER'S INSURANCE WAIVER I am aware that the licensee does not have the in --- - � — and — —- insurance coverage requiredbar Chff ec 14Z of the . - —-- that my signat re on this permit application waivesthis requirement . CHECK ONE ONLY: OWNER [3 AGENT [ . • SIGNATURE OF OWNER OR AGENT . - I hereby cry that all of the r i►s and ii;all lictaiii I have suba ted or entered regarding this app&on are true and accurate to the best of my knowledge • and that all plurairig work and moons performed under:the pew issued for this appruzdon writhe in complanceall P ent - M use State Plumbing Code and Chapt 142 of the General Laws. Pr tam of the kaVrenlie PLUMBER-GASI-11 I EX NAME 1 Dta v a M Cre&S,Si ►A LICENSE Z of7 SIGNATURE • ,_ • Li MGF 11 . ' N... .JGF j LPG!0 CORPORATION ER I I PARTNERSHIP D• 1 LC ' . 'COMPANY Nikkei D v h 1g e P1 um(,e r • f•ADDRESS • Cm' (\`. -s:r_ 't- i STATE MEILP 0 26.3c1 _ _ frt.'5Ob -"S 9_6732, 3 . 1 -' FAX L---- JCELL 18Lvek+ . •l u rv\b e r, c c.i.Y\ • ' • The Commonwealth of AMncsarhusetts - I.=—•l - - Department of Indtufrial Aced" rue - - . 1M: 6.Offrce 00 hingto Investigations - Boston,MA 02111_ • .. .:' :r�-`v�, www massgOV/dja - Workers'Compensation insurance Affidavit:BuilderslCouiractors/Eleclriciaus/Plmnbers . _ . APO&rant Information -Please Pirint Legibly '1 Name nor n- a)aV d mcCtt)ssi^ Address: Po O k 352_ city/sLt--: :... -mot 1 Are you an employer?Check the appropriate bon • I Type of project(required): r r-0 1 ., Sil?< • 4.fl Iamagenezalcouracmr•and1 , 5. Arc c a Lr. i.u a am a ees j * - have brad the b-coni.e.tn.e . employees(fun and/o r partime}, listed on fhe attached chee t- 7. 0 Remodeling 2�I am a sole proprietor or partner- These sub c have 8. 0 Demolit on ship an employees � andhavewodmrs' - :working for ar mt is sus capacity' comp.:n n�$ 9- 0 Building addition [N3 worb.c uncap.u S�auL1 5.❑We are a corp on and its MO Electrical repairs ill atLlitiuu. -— • _q 0 ...,.,.,.._ ,-.i... :wadi - ..-aframislave i'm-Fasedl3ic r-_ -11-[]--rh,u,Lmg r s or additions myself[No wa dce s'email. - of ez rorpoiP Per kkrI. 12 Lf Ruvf 3,i�:. c.152,§1(4),mid we have no insrance caterer d]t - - employes[No worked'. 13.0 Other camp.insurance regnued] *Any appyaont-t1at chocks box in ohm Jill catthe soinn helonrsboviag ihniSwcaiond compensation polity ice. t How who sabamtthis aiSdavit LeSating they ins doling aII work rad rhea L'aeanisi*motadanmstsubmit anew affidavit mrrn-+t:.,e cm-1, fr...t..N,In fat cheek this boa oastattachod an edditnmal shed showing tho moo ell.submdmdos and stain whe*e co*not thosc Lave employe.If the sub Fine®pbRes,Eby irmstproivicletheir w oks&eongopoticy'isasba-- ..-. -.. -- j Can we employer that is pro isrrng workers'roagrevrsatket uamoneefor my employees Belau is the policy and job site urformafi ' Insurance Company Name: • Policy#or Self-ins_Lie.#: con Date. • Iob Site Address_• City/Siam/Pp: copy a copy of the workers compeosatioupancy declaration age-(shawn<g-rite-policy numoer and cep a or.�w). Failure to secure coverage as raic;a..d under Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a - . fine up to$1,500.00 and/or aae-yea logisonmen,as well as civil penalties in the'fan of a STOP WORK ORDER and a fine - - of up to$250.00 a day trga;nc the violator.Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance wvetage warm m . I do hereby co-tfy order the pars wed penalties ofperjwy that the mlorm zdwi proi'ided siwaratnrc Ozone is rind correct • G�� "M,. .Date: (61 2•.Z 1 • , . -. Phone# sog ` 8 - �� Q . Official¢se only. Do not wrhe be dtfs area,to be completed by coy or town o_,1rrl - • • Cny or Town: - PamttiWense# Issuing Authority(circle one): Plumbing Board of Health 2 8>��g Department3.CStyftown Clerk 4.Electrical Inspector 5. Inspector 6.Other - • Contact Person: Phone#: