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HomeMy WebLinkAboutBLDG-21-006516 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1_' _:�7 CITY YARMOUTH MA DATE May 10,2021 PERMIT# BLDG 21-006516 JOBSITE ADDRESS 43 ELDRIDGE RD OWNER'S NAME CHESTER CHRISTOPER M G OWNER ADDRESS CHESTER NANCY 166 LOCUST ST DANVERS MA 01923 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111 PRINT CLEARLY NEW: 0 RENOVATION:D REPLACEMENT:0 PLANS SUBMITTED:YES ❑ 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 , DIRECT VENT HEATER DRYER FIREPLACE , FRYOLATOR FURNACE , GENERATOR 1 GRILLE , INFRARED HEATER , LABORATORY COCKS MAKEUP AIR UNIT OVEN , POOL HEATER , ROOM/SPACE HEATER , ROOF TOP UNIT , TEST 1 , UNIT HEATER • UNVENTED ROOM HEATER . WATER HEATER , OTHER 1 • OTHER DESCRIPTION:Garage Heater INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF 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. 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 John Downey LICENSE# 32070 SIGNATURE MP❑ MGF 0 JP© JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 137 Bray farm Rd North, CITY (Yarmouth port STATE MA ZIP 02675 TEL 15082155757 FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE:$ PERMIT# PLAN REVIEW NOTES