HomeMy WebLinkAboutBLDG-15-002151 t
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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'''..lige- t CITY Yarmouth MA DATE 5/12/14 PERMIT# �/s'aoa�.�
JOBSITE ADDRESS 14 Rainbow Dr. OWNER'S NAME Brian Serpone
GOWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES El NOD
APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER t 1 di 1 . I I
BOOSTERI 11
CONVERSION BURNER 1 :1-______I__�I
COOK STOVE
DIRECT VENT HEATER q1 t 9 ..`
DRYER ( I r I,
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FIREPLACE I i 1 '�
FRYOLATOR di i = 0 1
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FURNACE I II III i
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INFRARED HEATER itilitilOtWalliallianillintatlitiMMIKSISIMMISIS
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POOL HEATER i' HfiiJw(..1J.PF� e1MI" I ....� x tiaue ,r avr• 1
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ROOM I SPACE HEATER }l / _ _ t
ROOF TOP UNIT 1
TEST I 1
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ENTED ROOM HEATER
WATER
WATER HEATER
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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 0 OTHER TYPE 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.
CHECK ONE ONLY: OWNER ❑ 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 best of my knowledge
and that all plumbing work and 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 R.H.Whittle LICENSE# 11648 I SIGNATURE
MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP[# LLC❑# 1
COMPANY NAME:R.H.Whittle P&H ADDRESS 67 Owl Pond Rd.
CITY Brewster STATE MA ZIP 02631 TEL 508.255.9223
FAX CELL 774.722.1020 EMAIL stratpower@comcast.net
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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 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES