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HomeMy WebLinkAboutG-20-884 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK } ,�,'. ` CITY YARMOUTH MA DATE August 16,2019 PERMIT# BLDG-20-000884 I; ,_ JOBSITE ADDRESS 21 CARVER RD 1 OWNER'S NAME WAITE STEPHEN G G OWNER ADDRESS WAITE THERESA 9 BROUSHANE CIR SHREWSBURY MA 01545 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS—0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER - CONVERSION BURNER COOK STOVE - _ _ DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 _ GENERATOR _ GRILLE _ INFRARED HEATER LABORATORY COCKS - MAKEUP AIR UNIT OVEN - POOL HEATER _ ROOM/SPACE HEATER ROOF TOP UNIT - TEST - - UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 i 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 El 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 mark Kooyomjian LICENSE# MA SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: Kooyomjian P&H ADDRESS. 27 Cumberland Drive, CITY West Boylston STATE MA ZIP 01583 TEL 5088356700 FAX CELL 5087699873 EMAIL /t' Y- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 1'}G ri N4 (JyL FEE: $ PERMIT# /4i3/141 CAS PLAN REVIEW NOTES