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HomeMy WebLinkAboutBldg-19-003563 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK " BLDG-19-003563 kl-10 CITY YARMOUTH MA DATE December 12,2 PERMIT# JOBSITE ADDRESS 881 ROUTE 28 OWNER'S NAME GREEN CAVALIER LLC G OWNER ADDRESS 111 HUNTINGTON AVE#600 BOSTON MA 02199 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES© NOD FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 2 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER 3 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT 1 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 ❑ 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 Walter Kenney LICENSE# 9202 SIGNATURE MP© MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: plumbing&HVAC ADDRESS 23 Summerwind Lane, CITY N.Falmouth STATE MA ZIP 02556 TEL 5085635373 FAX 5085646681 CELL 5088891864 EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES /n //��� ,�C�� /� /� �/ Yes No (Y/' ✓ (/ r�' ZC,/1 THIS APPLICATION SERVES AS THE PERMIT❑ ❑ /a/M J/� FEE: $ PERMIT# / PLAN REVIEW NOTES