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HomeMy WebLinkAboutBLDG-22-000635 i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CUITY YARMOUTH MA DATE August 04,2021 PERMIT# BLDG-22-000635 1., : JOBSITE ADDRESS 120 EVERGREEN ST OWNER'S NAME John Christopher G OWNER ADDRESS MA 02343 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID 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/SPACE HEATER ROOF TOP UNIT TEST 1 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❑ 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 (Corey Sibbio LICENSE# 24795 SIGNATURE MP 0 MGF 0 JP© JGF 0 LPG! 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: COREY SIBBIO ADDRESS. 1190 PLUM ST, CITY 1W BARNSTABLE STATE MA ZIP 026681436 TEL 1 FAX CELL EMAIL (fccqunsmithing(fD,gmail.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 _ sa'�.4.• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .= CITY J t Y/4/.110 U 7.19 MA DATE O / 3 /61 1 PERMIT# 27- co3 c- 26 JOBSITE ADDRESS 102 D 'U., 7/ E,(it) OWNERS NAME L7 f-I i i s1 o p11Efa GOWNER ADDRESS S i1 M e / TEL 776 /2 3 7 6770 FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL ❑ RESIDENTIAL tgj (v PRINT CLEARLY NEW: 0.- RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES CINOikr APPLIANCES 1 FLOORS--F BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 I BOILER --1 L BOOSTER t lK1 C_V E D 0 CONVERSION BURIBURNER . COOK STOVE i I DIRECT VENT HEATER lif- 4 DRYER ' ' � - ' — FIREPLACE FRYOLATOR 1 ey. C T FURNACE - - .--f GENERATOR IGRILLE INFRARED HEATER LABORATORY COCKS ' MAKEUP AIR UNIT OVEN POOL HEATER f - ROOM ISPACE HEATER ROOF TOP UNIT TEST4_ . .. . .. _ .._.__ • .---- -- --- UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I INSURANCE COVERAGE - I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES t'NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY le 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 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT ri, 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 compl nce with all Perti nt provision of the `` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Lo PLUMBER-GASFITTER NAME LICENSE#a?1/7f 5..- 'IGNATURE MP❑ MGF❑ �JtP JGF❑ •LPPGI❑ CORPORATION❑tF PARTNERSHIP 0# LLC❑# (_ COMPANY NAME C/nL y . I `.�R to ADDRESS 7 �1' AU gL' i'( 0 g- CITY C�&)Tk�e ii 11 hel STATE WI $ ZIP O ‘3 o- TEL 56%ilit FAX CELL 5-6 g .Kg S-'/� 5-- EMAIL 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