HomeMy WebLinkAboutBLDG-19-002453 5 ay-0q-gigg r
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY 'WEST YARMOUTH MA DATE;10119118 PERMIT#frz n °21/67
1 JOBSITE ADDRESS'39 HARBOR ROAD I OWNER'S NAME FOLEY
GOWNER ADDRESS !39 HARBOR RD I TEL 781-752-6539 f FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL j EDUCATIONAL ❑ RESIDENTIAL
PRLVT
CLEARLY NEW: RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES j NOD
APPLIANCES 1 FLOORS–. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER •
BOOSTER
CONVERSION BURNER T' T•
COOK STOVE T _
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE . ';
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN �s •
s
POOL HEATER _
ROOM/SPACE HEATER
ROOF TOP UNIT : $
—
TEST — • #
____r
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER s —
OTHER I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 121 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY = OTHER TYPE INDEMNITY [J 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 21 AGENT
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 of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in pliance with all P in rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r
PLUMBER-GASFITTER NAME';ADAM TRAYNER ,LICENSE# 3880 SIG ATURE
MP J MGF'21 JP U JGF J LPG!i.„„j CORPORATION 21# 173 PARTNERSHIP U# LLC J#
COMPANY NAME:ROBIES HEATING&COOLING ADDRESS'279 YARMOUTH RD
CITY i HYANNIS --- I STATE I MA l ZIP,02601 1TEL'508-775-3083
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FAX 508-51272 I CELL'508-775-3083 1EMAIL MARY@ROBIES.COM
34-
ROUGII GAS INSPECTION NOTES TIIIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Jt /� Yes No=; 2 "` J' die THIS APPLICATION SERVES AS THE PERMIT 0 ❑
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/ // FEE: $ PERMIT#
`�'- /4 ////thr PLAN REVIEW NOTES