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HomeMy WebLinkAboutBLDG-21-004440 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK c r7s CITY YARMOUTH MA DATE February 05,2021 PERMIT# BLDG-21-004440 JOBSITE ADDRESS 92 WAMPANOAG RD OWNER'S NAME HOGAN STEPHEN G OWNER ADDRESS HOGAN NANCY 109 BURROUGHS RD BRAINTREE MA 02184 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 1 DIRECT VENT HEATER DRYER 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❑ 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 David McCrossin LICENSE# 21694 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# 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 I V•I e r--V e. 5 C a ,." (•, p A -►d & C K.. - , - MASSACHUSE i i S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS }-i I i ING WORK . . , _ CITY Li-44 ,- u ., MA BATE J / `�.�-• PERur# )G."21 --O JOBSITE ADDRESS 9 �, , ,f a rh p a nun: ) r ci A OWNS NAME , Ste✓c n C Ce G OWNIEtADORESS - I , 3 A // ..� i Tal 97 '3 7-C7i FAXf i •• FOR OCCUPANCY TYPE COMMERCIAL_0 EDUCATIONAL U RESIDEI�I"IAL.a • CLEARLY RLY NEW:0 RENOVATION:LI REPLACEMENT PLANS SUBMfITH): YES n NOD APPLIANCES 1 FLOORS-4 BSM 1 2 ' 3 ' 4 5 ' $ 7 - 8 9 10 I 11 12 1 13 14 — BOILER • i__ _—I= 6 • _-___/- 4 ti • BOOSTER . I P i ` 11 i r ` CONVERSION BURNER WI COOK STOVE. • - a I ; - j �..-1. _1_1 ._ ._I - I _____ 0 DIRECT VENT HEATER i • - t- , DRYER - € R5b.-. FIREPLACE I _ _ _Nuilit - i _ 1 - . FRYOLATOR • . 's FURNACE - • - i ' f i t___Jig, In I1 ; ii i i - GENERATOR GRILLE ° r_ ____-_t__, -____J____i _._ i - - -- tA _ _ LABORATORY COCKS €— i,_- - i.-..-- ' '---- „_ � if MAKEUP AIR UNIT = - t � - , `° B ; ;_M = L _ • POOL HEATER _ AM:IM — _ I t ROOM l SPACE HEATER • n' #1 _, i — �' _ • ` r r�� -- h i t ROOF TOP UNIT L �� TEST • }—J.___ i— - !' UNIT HEATER __it ti _ MINIM i UNVENTED ROOM HEATER a - . - - Ii ________ '__ WATER HEATER - L— i a i - : • ! - t i_____ • OTHER 1 I I _ - 1. NM I 1_ - ;�`` - JMM_____J • _ °__ = LI- Imo:- • -.-_-_J INSURANCE COVERAGE• • I have a current liability insurance policy ors substantial equivalent which meets the requirement of MGL Ch. 14Z YES NQ [ • I IF YOU CHECKED YES,PLEASE MEDICATE THE TYPE OF «• • • r,- : CHECKING THE APPROPRIATE BOX BELOW - LIABILITY DISURANCE POLICY [ OTHER TYPE INDEMNITY E, BOND D --- OWNER'S INSURANCE WAIVER II am aware that the licensee does not have the insurance coverage required byCh peer 142 of the _ • Massach , and that try►sign et i on this permit application waivesthiss requirement —-- • - CHECK ONE ONLY: OWNER El AGENT • SIGNATURE OF OWNER OR AGENT • i hereby certify that ail of the details and luTut,noun I have submitted or entered regarding this appfcafon are true and accurate to the best of my knowledge • • and that all plumbing work and installanons performed under the permit issued for this appl'rcafforz will be in c omprrance with all Peaiment he - Massachusetts State Piurnbing Code and Chapter 142 off General Laws. • provision oft AWL!) 1 1?- )A4141AN • PLUMBER-GASH/ I rR NAME# f )ca.v a ck f\1 y L 4 c;, _ 1 n___ 110ENSE#oi!b'1'1 SIGNATURE , le ! MGF 0 .IP a JGF LI LPGI El CORPORATION ER 1 _ f PAFUNERSHIP D#- 1 itc Dt=. • . COMPANY NANTOt.i v t The Fi y,Y,1i c' r • ,•ADDRES CITY .Ii., a A. S P ' _ STATE ciara ZAP CL;. 1 c i' 1 ITEL1 _ -., 1.- ` - • 18 FAX iC : 'a - C va g 7rRt• ,,.1 ,07\. ," ve• - � s� +r � 6 CG svN 43VI- • The Commonwealth ofMassachusetts - Department of Industrial Acad..' - •'_1=5 .Qf ce of Investigations . ' -. _: 1- l - 600 Washington Street z -- Boston,MA 0211I— - -•- • - - www.anass.go-v/dia - Workers'Compensationlnsrarance Affidavit:Builders/ContractOrsfElectricians/Plu bens . _ . ApFlicant Information• •Please Print Legibly Name(BasimrslOrgana R^ n" a,v%Ok. • M( 1 l D S S h .1 • • And»: • E. 0.* • 3 S • • ramCrty ,,r n.c} V� oa �#�-_ _��c�4a •3 .5 s Are you an employer?Check the appropriate bon •_ Type of project(required): r L❑I am a emplayerwith ' 4•0 I am a genial coniractor and I 6_ ©New construction employees(fail and/or part-lime)-' bay.hied t1 h �^ 2. I am a sole proprietor or partner- listed on attaryted sh rr 7. Remodeling ship andherve no employees These sub-ctmt have • -8- 0 Demolition working for me in any capacity employees and have waiters' - 9- Q Budding addition • -- wq,,' iasor-wnnl - - - aired] _ • 5-f]we are a won and its to jj Electrical repairs oral oaf — regns - _ _ work ...africniwhapeeseccselthnir'_ -711.0—Plumbiugrepairsorraddhions-. o workers'coop. Ruofrcpaas - — • insm-snce��]t , _ c•152,¢1(4),and we have no 13.0 Other employees w[No otiecs'. • mmp insurance rutuiial] •Ary sppFuant-thatcited.bail most also t5 aotfls aeon bdawshowing the•awmasa' IaItey i . t Hmatowaca who sabmitthis atBlarvit muting they aye d°ag all wockafld then lmeaerla4a contour=an=submit anew affidavit haroestleg arch :0,,.,t,m that ddedc tha Itom,,stehrimd m Ebel shirt sbow:vsg 9s=me oftbe sah-coateerscs and Orli wbeta co not those m•have employees_lithe sue- Sve emPloYeeS,fferisestPavide the waders'cry Porz9' - ---. -.. --- -- I am me employer that is providing workers'compeasatimt itrsarmtce far my employees Below is the policy and job site -information. . Insurance Company Name: . Po$cy#or Self-ins-Lit.5: ' Expiration Date- Job Site Address• City/Slate/Zip: • Attach a copT�.O $tC woritere-compensatinnpouey declaration page(sh_ozing the policy-nvmber and-ezpiraficn-date). Fatlree to sense coverage as require. d code Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/r one-year intpiisomaetd,as well as ant penalties in the fart of a STOP WORK ORDER and a fine • slop to$250.09 a day against the violator.Be advised that a copy of this stafr:nrerd may be forwarded to the Office of Investigations of the DIA for insurance coverage vafficatitn. I do herebythe pans ardpert esslit o�fp_er�jwy iha the irfarmatwa provided abcv is true earrc2 • Sienemrer c�j —J ur^ Liao- Date. ��) 5 ?1 Phone#. - ••5 •- 3 O -3�ZS 3 . • Official use only. Do not write be this area,to be completed by city or fawn oftsal • • ParaiM3se^_se . Cit3 or Town: . Issuing Authority(circle one): • L Board of Health 2 Building Department 3.C•tyiToWr Clerk 4.Electrical Inspector'5.Plumbing Inspector 6.Other- - Coataet Person: - Phone#r .