HomeMy WebLinkAboutBLDG-20-000072 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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lira CITY WEST YARMOUTH MA DATE 6/05/19 m _ I PERMIT# ///,76" a'a"7.2L
JOBSITE ADDRESS 88 ANSEL HALLET ROAD _ 'OWNER'S NAME OPHTHALMIC CONSULTANTS/BOSTON 1
GOWNER ADDRESS 88 ANSEL HALLET OAD TEL 508-534-6004 FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL ij EDUCA RESIDENTIAL___
PRINT
CLEARLY NEW: RENOVATION: _,` REPLACEMENT: ,./.:_ 4/) PLANS SUBMITTED: YES 1 NO
APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ..__ __ .___ ___ 1 _ _sj ____
BOOSTER I I __
CONVERSION BURNER
COOK STOVE I -
DIRECT VENT HEATER
DRYER < . ,__.. ... .... ... .w_. __ i ___.,. .. 1 _jj, I _.w _.____ 1
_ .
FIREPLACE
FRYOLATOR
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FURNACE 1 1444 if(' 1 f i
GENERATOR
.
GRILLE I . _
INFRARED HEATER
LABORATORY COCKS I
MAKEUP AIR UNIT s .._._ _..u_ ._, _ . __ ___ I ____ I _. 1 _____1
OVEN I _ _._I __I __ t _j I __.____J i
POOL HEATER _
t
ROOM/SPACE HEATER ; _ '
3
ROOF TOP UNIT I 1 _., 1 _
:
TEST t I I ____:1
UNIT HEATER _ i
UNVENTED ROOM HEATER .w..., _...__._ _..._
WATER HEATER r
OTHER N I _ _€
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I!`_- NO _„
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY _i 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
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"•the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will 'n mpliance 'th . ••ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME ADAM TRAYNER LICENSE# 3880 SIGNATURE
MP _! MGF v JP JGF LPG! . j CORPORATION i # 173 PARTNERSHIP _- # LLC #
COMPANY NAME: ROBES HEATING&COOLING ':ADDRESS 279 YARMOUTH RD
CITY HYANNIS STATE MA ZIP 02601 .TEL 508-775-3083
FAX 508 534 1272 CELL 508-775-3083 =EMAIL MARY ROBIES COM
Onot Vial
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# /J�
PLAN REVIEW NOTES IJ�± ' _ (•e��
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