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HomeMy WebLinkAboutBLDG-19-001231 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '"" CITY YARMOUTH MA DATE August 28, 2011 PERMIT# BLDG-19-001231 ,` JOBSITE ADDRESS 53 COLLINGWOOD DR OWNER'S NAME TIETGE ROGER P CT OWNER ADDRESS TIETGE CHARYN A 53 COLLINGWOOD DRIVE YARMOUTH PORT MA TEL 02675 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW 0 RENOVATION.❑ REPLACEMENT:III PLANS SUBMITTED:YES❑ NOD 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 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 0 NOD IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY❑ 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 perfumed 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 Donald Mercier LICENSE# 31082 SIGNATURE MPD MGF❑ JPO JGFD LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Donald R Mercier ADDRESS 4 WILDWOOD WAY, CITY SANDWICH STATE MA ZIP 025632686 TEL FAX CELL EMAIL r.. 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 ._Y • =S MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK T17 k 7� /� lLt_ `7 CITY Yarmouthport MA DATE 8242018 PERMIT#/J��7 Oa 123/ -1- JOBSITE ADDRESS 53 Collingwood Drive OWNER'S NAME Roger Tietge GOWNER ADDRESS Same TEL508-362-3441 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL] EDUCATIONAL[l RESIDENTIAL[ J PRINCLEARLY NEW:[1 RENOVATION:[,j REPLACEMENT:21 PLANS SUBMITTED: YES Li NO 2j APPLIANCES 1 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 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM!SPACE HEATER - ROOF TOP UNIT TEST L UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES fit NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 21 OTHER TYPE INDEMNITY [_ 1 BOND ri 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 J 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 nd 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 comp) ce with •I P '--n • •.r i-ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER-GASFITTER NAME Donald R Mercier LICENSE#31082 S GNATUR: MPC] MGF U MGF Li JP'iIZ) JGF LPGIEJ CORPORATION[;# PARTNERSHIP E# LLC F—# COMPANY NAME:Barnstable County Plumbing&Heating ADDRESS 4 Wildwood Way CITY Sandwich STATE MA ZIP 02563 TEL 508-420-5919 FAX CELL 508-420-5919 EMAIL bcph08@gmail.com