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HomeMy WebLinkAboutBLDG-22-001568 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rt �'ktz. BLDG-22-001568 e CITY YARMOUTH MA DATE September 20,202 PERMIT# JOBSITE ADDRESS 15 DANBURY ST OWNER'S NAME CASARANO JOSEPH J JR G OWNER ADDRESS ICASARANO BARBARA J 12 MURDOCH ROAD STONEHAM MA 02180 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER , CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR • FURNACE GENERATOR • GRILLE INFRARED HEATER , LABORATORY COCKS MAKEUP AIR UNIT , OVEN , POOL HEATER ROOM I 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 0 OTHER OF INDEMNITY 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 (Joshua Depina LICENSE# 15756 SIGNATURE MP© MGF 0 JP 0 JGF 0 LPG( 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: (JOSHUA V DEPINA ADDRESS. IPO BOX 2502, CITY ITEATICKET I STATE MA ZIP 025362502 TEL I FAX CELL EMAIL Iivdepina aagmail.com 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 , 4SD.Da r - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - , F'r �CVY i; (moQrtti MA DATE R- /) ')-1 PERMIT# LZ- (Slog 1 ITE ADI RESS / e) (...))„A 6vr1 OWNER'S NAME Jot Casarc‘nv 1�_ OWNER D ,ESS TEL FAX B,g..)i--i)E'PR iM.IENT fa5t>Li� --'C~CUP_ANC TYPE COMM• ERCIAL E EDUCATIONAL ❑ RESIDENTIAL`Q CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 14 BOILER BOOSTER ---1CONVERSION BURNER _ COOK STOVE ______1 r DIRECT VENT HEATER , DRYER `---� FIREPLACE —~ FRYOLATOR FURNACE GENERATOR GRILLE 1 . INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 11 ROOM I SPACE HEATER 1 ROOF TOP UNIT TEST -. . . UNIT HEATER UNVENTED ROOM HEATER I I WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES.421 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ 1 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. i CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT . :s 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 `1;- 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. � t PLUMBER-GASFITTER NAME 30511,4 DP.,_ LICENSE# !S-7C6 SIGNATURE MP MGF 0 JP�Fa JGF❑D LPGI ❑ CORPORATION❑41 PARTNERSHIP 0# LLC El# r COMPANY NAME e J,Ae. i t c,01 L.t,�.3 ADDRESS pu a-cc )-- CITY CITY TeaI<<t- STATE MA ZIP U 7 S ? .-- TEL 5-0 IC 5666395 FAX CELL EMAIL .� f" 1�'rdl ,S a"`�' 1 ' �0Y'' 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 • • • • •