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HomeMy WebLinkAboutG-18-5224 ..s MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,,, CITY YARMOUTH MA DATE March 23,2018 PERMIT it BLDG-18-005224 JOBSITE ADDRESS 4 HOMERS DOCK RD OWNER'S NAME ELLIS IAIN G OWNER ADDRESS ELLIS CATHERINE CALDERARO 4 HOMERS DOCK RD YARMOUTH TEL PORT MA 02675 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL al PRINT CLEARLY NEW m 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 1 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 © 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 codify 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 Richard Olsen LICENSE# 2166 SIGNATURE MPO MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# • LLC❑# COMPANY NAME: THE HOKUM ROCK CORP ADDRESS PO Box 2026, 357 Hokum Rock Rd, CITY Dennis STATE MA ZIP 02638 TEL 5083855290 FAX [ CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT❑ ❑ FEE:$ PERMIT# I7111Mite 0' anw PLAN REVIEW NOTES /y/ die — lI / Away A & VOW g &Frye/2— e ,iw