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HomeMy WebLinkAboutG-19-1728 51101/0 r ,-o avm MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I, . CITY YARMOUTH MA DATE September 22, PERMIT# BLDG-19-001728 JOBSITE ADDRESS 25 ANASTASIA RD OWNER'S NAME LHEA MAUREEN N G OWNER ADDRESS SHEA JOHN D 25 ANASTASIA ROAD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL D PRLNT CLEARLY NEW 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD FIXTURES FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 © NOD IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY El 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. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are hue and accurate to the best of my knowledge and that all plumbing work end 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 Peter Jones LICENSE# 13577 SIGNATURE MP© MGC JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP 04 LLC❑# COMPANY NAME: ADDRESS 6 chickadee In, CITY w vermouth STATE MA ZIP 02673 TEL FAX CELL 5082375207 EMAIL 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 ttlAtC- 6/5 Oti �d6fp