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HomeMy WebLinkAboutBldg-19-003557 (2) r, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 9 CITY YARMOUTH MA DATE December 12," PERMIT# BLDG-19-003557 JOBSITE ADDRESS 44 MADISON AVE OWNER'S NAME MARSHALL SHAWN G OWNER ADDRESS 44 MADISON AVE SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW ❑ 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 1 DIRECT VENT HEATER f s� DRYER FIREPLACE (w\, FRYOLATOR FURNACE GENERATOR GRILLE 1 INFRARED HEATER 1/V • LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER _ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 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 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 Spencer Hallett LICENSE# 16224 SIGNATURE MP© MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑#_ PARTNERSHIP ❑# LLC❑# COMPANY NAME: Spencer Hallett ADDRESS 18 EASTVIEW TER, CITY MARSTONS MLS STATE MA ZIP 026481372 TEL FAX CELL EMAIL 1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK — = CITY .,,ql/y/OGt,/1 MA DATE a'/O PERMIT#B'i'R 00- 2 f JOBSITE ADDRESS !Y .470, -Tc',1 4/t OWNER'S NAME,9'74 4 ?' 61 e 7Z POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL' PRINT CLEARLY NEW:Rr RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMI I I ED: YES'NO❑ FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICA I EU SPECIAL WASTE SYSTEM H DEDICA I EU GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ • DED ICA I ED WATER RECYCLE SYSTEM DISHWASHER l • DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR!AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK / LAVATORY _ RDOF DRAIN SHOWER STALL SERVICE/MDP SINK ` r; '; TOILET URINAL WASHING MACHINE CONNECTION C WATER HEA I ER ALL TYPES WATER PIPING OTHER I I I I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YESW NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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 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 Bo; rte 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 c, :II Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE#/i 74/ . SIGNATURE MP V JP❑ // G CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME AG G y L7 ADDRESS CITY /V 1,� c� r�"' STATES ZIP ���y9 TEL FAX CELL EMAIL yC ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No 0#- / THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ "' iV FEE: $ PERMIT I `tom /1L-3 PLAN REVIEW NOTES Tith e /2//' •