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HomeMy WebLinkAboutBLDG-16-003807 BLDG-16-003807 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK s-= kp_ CITY Yarmouth MA DATE 12/18/15 PERMIT# -Db—4—6o%'a7 JOBSITE ADDRESS 7 Mirror Brook Road w ya& oQ7MOWNER'S NAME Blake GOWNER ADDRESS Same M#58 P#377 'TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL El PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 GO PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 I i 1 fi BOOSTER �' , ' . 1 CONVERSION BURNER y COOK STOVE ' i I DIRECT VENT HEATER DRYER ,1 [ -. I . FIREPLACE � � f �,, FRYOLATOR , J 0 I 11 il fi FURNACE ._1 : 1 i ' GENERATOR lk GRILLE 0 1 ' U 11 1 _J fi INFRARED HEATER � r 1 Id � t f LABORATORY COCKS MAKEUP AIR UNIT J U, 1OVEN 1 1 i ' . i POOL HEATER f _ ROOM/SPACE HEATER t , ,_ , '�, ) fi ROOF TOP UNIT _ 1 TEST I 11 UNIT HEATER 11 UNVENTED ROOM HEATER f t !' I WATER HEATER 1 I 1 OTHER 11 11 1 II t1 I I ., ., H INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE 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 El 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 accur. - .the b of y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance • -erti t pr sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME James Pazakis LICENSE# 15030 RE MP 0 MGF 0 JP❑ JGF© LPG'❑ CORPORATION❑# PA'," , RSHIP LLC❑# COMPANY NAME: Self ADDRESS 158 Whittier Drive CITY Dennis STATE MA ZIP 02638 TEL 508-258-0513 FAX CELL EMAIL Halltechnician@comcast.net 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