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HomeMy WebLinkAboutG-15-2573 N MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK JJ= CIN �� lJd� : e MA DATE I//ac//l PERMIT# itt-Ob-15-4ds(CT3 JOBSITE ADDRESS:f D,P,c /e1./ � / OWNER'S NAME: GaiP/?ti�`l/ d/i lt,ii�' GOWNER ADDRESS: a° �l 4egeLL� TEL: FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 ..RESIDENTIAL PRINT / 1 CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:J( PLANS SUBMITTED: YES 0 Nae APPLIANCES? FLOOR-4 Bsmt 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 GENERATOR GRILLE _ INFRARED HEATER LABORATORY COCK - MAKEUP AIR UNIT OVEN POOL HEATER ' ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER _ WATER HEATER INSURANCE COVERAGE _ �._...._... a I have a current liability0 insurance policy or its substantial equivalent which meets the requirements of MGA Ch.142: YES NO $ If you have checked YES.please indicate the type of coverage by checking the appropriate box belo�. F-7- u / V_ L LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ I NLBOND1lLIu,.i I XOWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter X42 of the i Massachusetts General Laws,and that my signature on this permit application waives this requirement',"_ _'_ I iCHECK ONE ONLY: OWNER❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT IN � 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 co pliance with all Pertinent provision of the Massachusetts Stattee.Plumbing Code and Chapter 142 of the General Laws p� ��� PLUMBERIGASFITTER NAME:,47 -yao c LICENSE#O�9yn 1 '�SI SIGNATURE 1 COMPANY NAME ' P 4_, G L// ADDRESS: .LL y(ia.��/.//!//•.1'/4/ CITY•16f,wledg % ZIPtad 7 FAX TEL: CELLbX'--fi #1312,,,‘ EMAIL: MASTER "JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0# LLC # ,171 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES - Yes No /�7 / MS APPLICATION SERVES AS THE PERMIT ID 1:1�j� ,i� c4E: $ PERMIT PLAN REVIEW NOTES ,- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1,-73e- CITY YARMOUTH MA DATE November 06,2 PERMIT# BLDG-15-002573 JOBSITE ADDRESS 9 ORCHID LN OWNER'S NAME MCCORMICK, LAWRENCE E G OWNER ADDRESS MCCORMICK, MARY L 51 CROSS ST BELMONT MA 02178-3168 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL © PRINT 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 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 0 NOD IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 0 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 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 GARY JONES LICENSE# 8890 SIGNATURE MP© MGC JP❑ JGFD LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: GARY C JONES ADDRESS 12 YEOMAN DR, CITY W YARMOUTH STATE MA ZIP 02673 TEL 3 FAX CELL EMAILI J 4 M ' ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No //1 7-19 THIS APPLICATION SERVES AS THE PERMIT❑ ❑ A /J� FEE:$ PERMIT# 4", " ' �/� -w PLAN REVIEW NOTES