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HomeMy WebLinkAboutG-19-2100 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I. CITY YARMOUTH MA DATE October 09,20' PERMIT# BLDG-19-002100 JOBSITE ADDRESS 12 ALBION ST OWNER'S NAME JOHNSON NANCY L G OWNER ADDRESS PO BOX 342 HYANNIS MA 02601 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO0 FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER • CONVERSION BURNER COOK STOVE • DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR • FURNACE 1 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 1 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❑ 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. SIGNATURE OF OWNER OR AGENT 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 JOHN O'CONNOR LICENSE# 11191 SIGNATURE MPG MGF❑JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: JACK O'CONNOR PLUMBING&HEA,ADDRESS 15 JAN SEBASTIAN DR, UNIT A5, __ _ _;_� CITY SANDWICH - STATE MA ZIP 02563 TEL 5088331424 FAX 5088887997 CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT❑ 0 FEE:$ PERMIT# PLAN REVIEW NOTES 1144 a �tCArn . . at ,