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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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iLi CITY SOUTH YARMOUTH ( MA DATE 18/13/18 I PERMIT#/),-06-79-600 767
JOBSITE ADDRESS!21 FOUR SEASONS DRIVE I OWNER'S NAME NEITERMAN
GOWNER ADDRESS !21 FOUR SEASONS DRIVE ` I TEL!508-760-2640 IFAXI
TYPE OR OCCUPANCY TYPE COMMERCIAL U EDUCATIONAL u RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:Li REPLACEMENT:H0 PLANS SUBMITTED: YES j N0,_]
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER r. "
BOOSTER 1 I=1, „—,_
CONVERSION BURNER
COOK STOVE '
DIRECT VENT HEATER - �I ^ " I! =!_ F,� •
• DRYER i
—
FIREPLACE
FRYOLATOR , H ' �,
FURNACE 1 ., 1. I t, , -
-- --, _r_.-_,'-- — ---r.- — �...- _
GENERATOR 1 ,• '1 ,T F r; y 4 �IT'h _r
GRILLE I " 4 , " .;In
INFRARED HEATER , 1 r r' r• -
LABORATORY COCKS F :r 'I IN i I
MAKEUP AIR UNIT f! 1
"�" ---9-- , , LL ""' -T"�-•'��....'
OVEN I� �, .' i Y t s, ,,
POOL HEATER 1 "I I i1 H
ROOM/SPACE HEATER � Y. I �1_-�' ''_`
ROOF TOP UNIT _ '_I r " u '_'I_ _!�_
TEST 1 e_-__ ___.___
UNIT HEATER i "!� l• .-i +
UNVENTED ROOM HEATER - " 1 I ti
WATER HEATER -� ' '' 6-T — —'
OTHER l
' T11 �ti
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D OTHER TYPE INDEMNITY U 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 that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER U AGENT U
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 pliance with all inent vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I ADAM TRAYNER I LICENSE# 3880 SIGNATU E
MP U MGF la JP r� JGF 0 LPGI!0 CORPORATION••U#1173 I PARTNERSHIP U#, I LLC D#. i
COMPANY NAME::ROBIES HEATING&COOLING I ADDRESS' 279 YARMOUTH RD I
CITY ',HYANNIS I STATE MA—(ZIP 02601 ITEL 508-775-3083
FAX 508-534-1272 1 CELL!508-775-3083 EMAIL!MARY@ROBIES.COM •
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
• Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
Plc 6/5 at
FEE: $ PERMIT#
I !T PLAN REVIEW NOTES