Loading...
HomeMy WebLinkAboutBLDG-19-000142 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK liskt,S L, CITY YARMOUTH I MA DATE July 09,2018 PERMIT# BLDG-19-000142 JOBSITE ADDRESS 120 CONGRESSIONAL DR OWNER'S NAME RANDALL MARCIA J GOWNER ADDRESS 20 CONGRESSIONAL DR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE i COMMERCIAL 0 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 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE ' FRYOLATOR FURNACE GENERATOR I _ GRILLE INFRARED HEATER LABORATORY COCKS I MAKEUP AIR UNIT I I , OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER I UNVENTED ROOM HEATER I WATER HEATER OTHER I 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 APPROPRIATEBOX BELOW LIABILITY INSURANCE POLICY © 11 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 tha my signature on this permit application waives this requirement. I i SIGNATURE OF OWNER ORGENT I hereby certify that all of the details and Information I ha a submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and Installations rformed under the permit issued for this application will be In compliance with all Pertinent provision of the Massachusetts State Plumbing Code aid Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Kevin Saundbrs LICENSE# 4546 SIGNATURE MP❑ MGF© JP❑ JGF❑ LPGI❑ I CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: KEVIN C SAUNDERS ADDRESS 67 HELMSMAN DR, CITY YARMOUTH PORT 1STATE MA ZIP 026752467 TEL FAX CELL EMAIL iiit • �? ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE:$ PERMIT# PLAN REVIEW NOTES _ I ! I I I II I I ! rizA0