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HomeMy WebLinkAboutBLDG-19-005149 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 11 1 CITY YARMOUTH MA DATE March 13,2019 PERMIT# BLDG-19-005149 JOBSITE ADDRESS 106 GREAT WESTERN RD OWNER'S NAME RYAN SEAN M G OWNER ADDRESS RYAN JESSICA L 106 GREAT WESTERN ROAD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO 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 FRYOLATOR FURNACE • GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ OVEN POOL HEATER ROOM 1 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 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 Richard Whiteside LICENSE# 15850 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPG! 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RICHARD J WHITESIDE ADDRESS. 29 MAPLE TER, CITY SOUTH DENNIS STATE MA ZIP 026603651 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El 0 FEE:$ PERMIT# PLAN REVIEW NOTES