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BLDG-19-002398
G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY IYARMOUTH MA DATE October 22, 20' PERMIT # BLDG-19-002398 JOBSITE ADDRESS 1352 WEIR RD OWNER'S NAME IFASANO PETER J OWNER ADDRESS IFASANO MONICA J 352 WEIR RD YARMOUTH PORT MA 02675 TEL OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL NEW D RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO© FIXTURES FLOORS —r BSM 1 2 3 4 5 1 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER. DRYER FIREPLACE 1 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 NO[-_] IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY[--] 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 true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pennit 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 Stephen Roberts LICENSE # 5104 SIGNATURE MP❑MGF❑JP❑ JGF❑ LPGI❑ CORPORATION❑#0 PARTNERSHIP ❑#LLC❑#� COMPANY NAME: ISTEPHENW ROBERTS 1ADDRESsF17 LAKE DR, CITY PLYMOUTH STATE MA ZIP 023605647 TEL FAX OCELL 0 EMAIL ROUGH GAS INSPECTION NOTES I THIS PAGE FOR INSPECTOR USE ONLY Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES FINAL INSPECTION NOTES