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HomeMy WebLinkAboutBLDG-20-000819 mfff' 0ihd‘?4r/7 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 17 '�' CITY YARMOUTH MA DATE August 13,2019 PERMIT# BLDG-20-000819 III JOBSITE ADDRESS 23 DAUPHINE DR OWNER'S NAME JANSON-LAPALME EDMOND J G OWNER ADDRESS PO BOX 623 YARMOUTH PORT MA 02675-0623 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 12 PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ 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 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 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 © NO❑ 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 (Cameron Natale LICENSE# GF4600-M SIGNATURE MP 0 MGF © JP❑ JGF❑ LPG! CI CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: I I ADDRESS. 1279 Yarmouth Rd, CITY Imarstons mills STATE MA ZIP 02648 I TEL 17743537354 FAX CELL 1 EMAIL 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 /1//,4' --- 6,5 // 0/7/5dt f42/./ / /dc/7