Loading...
HomeMy WebLinkAboutG-21-4890 t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK >kg.� BLDG-21-004890 �, y CITY YARMOUTH MA DATE March 01,2021 PERMIT# JOBSITE ADDRESS 15 BURCH RD OWNER'S NAME FERULLO GLORIA R TR G OWNER ADDRESS 26161 SUMMER GREENS DR BONITA SPRINGS FL 34135 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ED PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 FIXTURES FLOORS— 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 1 FRYOLATOR FURNACE GENERATOR GRILLE 1 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT 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 ❑ 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 0 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 David Houde LICENSE# 16673 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: MCDONNELL MECHANISCAL SERVICES, ADDRESS. 79 School Street, CITY Wet Dennis STATE Ma ZIP 02670 TEL FAX CELL EMAIL barbarafimcdonnellmechanical.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El El FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY a r/num f MA DATE PERMIT# QLO G --LE_Up 4Qg D JOBSITE ADDRESS / C a rC, OWNERS NAME 12 -es('/// 0 y, OWNER ADDRESS �/ 16 l f`'�'"k-$� �-i-.eeFl 0 TEL FAX TYOR vi" ' '7 `1 P""hSS r L PRINT PE OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL ❑ RESIDENTIAL DV CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO 0 APPLIANCES-1 FLOORS-4 BSM 1 2 3 1 5 6 7 8 9 10 11 13 14 BOILER / BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER • DRYER FIREPLACE _ J FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS . MAKEUP AIR UNIT OVEN POOL HEATER • ROOM!SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER INVENTED ROOM HEATER WATER HEATER OTHER 13 r3 Q I _ I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 a curate tot :°st o y knowledge `- and that all plumbing work and installations performed under the permit issued for this application will be in corn a ce th all P 11- pro-'sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Ca t4 l/ Li LICENSE# / �� 3• SI ATURE MP Er MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME l A�/(e f i,/ ADDRESS CITY 44` 4 Fc�j STATE/--- ZIP v6)" 6 y F TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES TI3LS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES