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HomeMy WebLinkAboutG-19-487 ✓• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK It, CITY YARMOUTH MA DATE July 24,2018 PERMIT# BLDG-19-000487 411 JOBSITE ADDRESS 111 GEORGE BRAY RD OWNER'S NAME LIEB JAMES M G OWNER ADDRESS LIEB1 PPiULP S 4 STAGE COACH RUN EAST BRUNSWICK NJ 08816 TEL TYPE OR OCCUPANCY TYPE 4OMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW 0 RENOVATION:ft REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NOD FIXTURES FLOORS--• BSM 11 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I I BOOSTER CONVERSION BURNER ; I COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN I POOL HEATER ROOM/SPACE HEATER I ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER • WATER HEATER 1 I OTHER OTHER DESCRIPTION: I I 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❑ 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 1 hereby certify that all of the details and Information have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations p=rforrred under the permit Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Cod:a •Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Kevin Sa nd-rs LICENSE#14546 SIGNATURE MPO MGF© JP❑ JGF❑ LPGI❑ C/RPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: KEVIN C SAUNDERS MUM ADDRESS 67 HELMSMAN DR, CITY (YARMOUTH PORT I 1 I STATE MA ZIP 026752467 TEL FAX CELL I 1 EMAIL Vl\ >° ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES es' No THIS APPLICATION SERVES AS THE PERMIT❑• ❑ FEE:$ PERMIT# PLAN REVIEW NOTES Cf 6A-5 dir r-saw-L & 19 ori /0 Ob 11 1.0W/ir II • •