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HomeMy WebLinkAboutBLDG-22-000620 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'is�' CITY YARMOUTH MA DATE August 04,2021 PERMIT# BLDG-22-000620 F,. JOBSITE ADDRESS 11 NORTH COVE LANDING OWNER'S NAME RODGERS JOSEPHINE W(LIFE EST) G OWNER ADDRESS RODGERS KENNETH W(LIFE EST)136 MARINER LN BAY SHORE NY 11706 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 FIXTURES FLOORS-I 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/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 El 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 Joseph Lemieux LICENSE# 10791 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPG! 0 CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: JOSEPH S LEMIEUX ADDRESS. 118 DINAHS WAY, CITY IWAREHAM STATE MA ZIP 025711463 TEL FAX CELL EMAIL Iis.lemsons(a!vahoo.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 v `. MASSACHUSETTS UNIFORM APPLICATION FOR A PE MET 0 PERFORM GAS FITTING WORK e"-^.,. 1 /7 CITYki(-,17-02--*/ MA DATE 7 02 PERMI 22- Co Z.,0 JOBSITE ADDRESS //l ��—/'k (2.0-24e /efrilv OWNER'S NAME //-/G e-‘ GOWNER ADDRESS <<c s1-c.._ TEL FAX TYPE OR OCCUPANCY TYPE COMMERCI ❑ EDUCATIONAL 9 RESIDENTIAL 11.--------- PRINT CLEARLY NEW:9 RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES 9 NO 9 APPLIANCES"1 FLOORS-4. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1" BOILER / BOOSTER { CONVERSION BURNER COOK STOVE DIRECT VENT HEATER i DRYER - FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT F I V OVEN POOL HEATER • { ROOM I SPACE HEATER -j 0-3 � - 6 ROOF TOP UNIT `J TEST - ..BUILDING OCI'ARTiJlnr ` UNIT HEATER a r _ --- p INVENTED ROOM HEATER • WATER HEATER OTHER V I S INSURANCE COVERAGE `0 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [41-1/011 1 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a.......---- OTHER TYPE INDEMNITY 9 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 0 OWNER ■ AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are 'ie - d a ural I�:"! of my knowledge `:- and that all plumbing work and installations performed under the permit issued for this application will be in c•. • .nc th,� rhnent provision of the `` Massachusetts State Plumbing Code-nd Chapter 142 of the General Laws. f/ ` Lo ► PLUMBER-GASFITTER NAME X %IV<e-44"LICENSE# /C / SIGN RE MPMGF❑ JP 9 JGF❑ LPGI❑ CORPORATIONIgl PA•TNERSHIP 9# LLC 9# COMPANY l AME ,5 al_e < G,.,� �4- `�' `-U - ADDRESS P 0• KC- 41- . CITY � - �-K Qh't.t_ STATE ZIP 60 6-7‘ TEL.C°7 . "29/ -/"--2 FAX CELL 61/ 17"JC C- ' 4e ) EMAIL S 14(.56't 5 <.1 , CU'^ e)V,4-'15 5i Li 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