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HomeMy WebLinkAboutBLDG-19-001228 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTHMA DATE August 28,2011 PERMIT# BLDG-19-001228 JOBSITE ADDRESS 1120 BAKERS PATH OWNER'S NAME SULLIVAN PAUL J JR G OWNER ADDRESS 120 BAKERS PATH SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El 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 (fa) • • • 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 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 © NOD IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 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 Michael Pasic LICENSE# 11512 SIGNATURE MP© MGFO JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# r COMPANY NAME: Michael K Pasic ADDRESS PO BOX 830, CITY COTUIT STATE MA ZIP 026350830 TEL FAX CELL EMAIL t •t , ,.a ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES' Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT# PLAN REVIEW NOTES r Val 6 2 ,,77 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rani �--�� CIT5 Ar tiAC JAA `� M(A� DA1TE` . Z3( 19 PERMITU[T I*BC -/9-40?I7 2- JOBSITEADDRESS 10 13r Y.-1,-(S rAT'T\ OWNER'S N.4MEU t .%vim GOM ER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENT PRINT CLEARLY NEA RENOVATION:0 REPLACEMENT:0 PLANS SUBMI I i EU: YES 0 NO 0 APPLIANCES I FLOORS-. RDA 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 • _ ^�, ,.. • a.MAKEUP AIR UNIT 1t-E E.EV E-D OVEN POOL HEATER >'� ROOM I SPACE HEATER . _., kG 21U1 i ROOF TOP UNIT y��ry UESTNIT . .. _. .... . . . ... ...._ ...... LD fZ VAR • — UNIT HEATER ? ? ' , UNVENTED ROOM HEATER WATER HEATER OTHER T INSURANCE COVERAGE 1 I have a current liability Insurance policy or its substantial equlvalentwhich meets the requirements of MOL Ch.142 YES-E3 NO 0 IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY-a OTHER TYPE INDEMNITY 0 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. CHECK ONE ONLY: OWNER 0 AGENT 0 J 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 acc -4- • 4- best of my knowledge '•- and that all plumbing work and Installations performed under the permit Issued for this application will be In co plian . r.: .y rtinent pro, on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. U) S PLUMBER-GASFITTER NAME LICENSE# \L512. SIGNATURE M I MGF 0 JP 0 JGF0 LPG'0 CORPORATION 0# PARTNERSHIP 0 it LLC 0# COMPANY NAME \AA. e . Y xscc.6 G am. 1/41---- E.Z ADDRESS.--?0 . &t ) �VW T r [ / CITY 6511,E r"% STATE VKl• ZIP Ozto n� TEL77 - u 3 FAX • CELL EMAIL 1 ACP✓151'nA'V -Cosh I ROUGH GAS INSPECTION NOTES I THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No • THIS APPLICATION SERVES AS THE PERMIT ❑ 0 . I FEE: $ PERMIT# 9` ' ' 0 4 2 IPLAN REVIEW NOTES'; r 't - /)/�c G� A' 1 v I I rik f I 1 j • • - .1 I . I ' . ..I - iI .4._,. 1 i 4 I I