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HomeMy WebLinkAboutBLDG-19-003573 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 01 CITY YARMOUTH MA DATE December 13,2 PERMIT# BLDG-19-003573 JOBSITE ADDRESS 23 AMOS RD OWNER'S NAME MITCHELL JOHN B G OWNER ADDRESS 23 AMOS RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ , RESIDENTIAL PRINT CLEARLY NEW m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO2 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 1 FURN43-R FURNACE \ GENERATOR - - _ -- GRILLE INFRARED HEATER LABORATORY N ` l �- MAKEUP AIR UNIT IT \ 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 El 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 . 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 Stephen Roberts LICENSE# 5104 - SIGNATURE MPD MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN W ROBERTS ADDRESS 17 LAKE DR, CITY PLYMOUTH STATE MA ZIP 023605647 TEL FAX L CELL EMAIL yRif ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT❑ 0 Rie ( 49 6/17FEE:$ PERMIT# PLAN REVIEW NOTES pi 1 11/647 k