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HomeMy WebLinkAboutBLDG-22-000799 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE August 11,2021 PERMIT# BLDG-22-000799 JOBSITE ADDRESS 54 CAPT RYDER RD OWNER'S NAME ambersley rohan G OWNER ADDRESS 54 CAPTAIN RYDER RD SOUTH YARMOUTH MA 02664-1631 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 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 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 ❑ 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 0 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 • S310N M3IA321 NNId #.I01213d $:33d ❑ ❑ .IJY J d all SV S3AI3S NOIlYOIlddV SIHI oN so), S3ION NOI103dSNI 1VNId KINO 3Sf1 H0103dSNI 2i0d 39Vd SIHl S310N NOI103dSNI SV9 HOf102! • y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �j Q �.� CITY � /G,r+�^-O �h MA DATE V I PERMIT#f 22— 191 JOBSITE ADDRESS S/ C a► t4'^ Q( ' Q /� p /�yR� ��l e� o�NhIER S NAME '`c�An !� p"%b�r5 OWNER ADDRESS 3 Vat�'W�(') ' `A TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT:isteTe,s+ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 PIZ BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER i FIREPLACE FRYOLATOR FURNACE __ GENERATOR GRILLE 7 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 F 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 COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 v., 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 impliance with all Pc nent provision of the `` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��__//_tlJJZ�p�// i PLUMBER-GASFITTER NAME'Da•Vi M e C r-o 5 S i h LICENSE# ' 1 (0 q 4 SIGNATURE MP❑ MGF❑ JP. JGF❑ LPG!❑ CORPORATION El PARTNERSHIP❑# LLC ElCOMPANY NAME pUr"b # 1�avt t ` i 'er ADDRESS 8 `�O' �ZM CITY�Po('A Z(STATE !" lPC ZIP Ov 3g TEL a(� -,3g0j- 3 a93 FAX CELL EMAIL &aye@ d a,we +he �L bes,tOW. 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