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HomeMy WebLinkAboutBLDG-21-002992 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `r ''1/4,,,,olCITY YARMOUTH MA DATE November 25,202( PERMIT# BLDG-21-002992 Ii JOBSITE ADDRESS 321 PINE ST OWNER'S NAME BREESE PROPERTIES LLC G OWNER ADDRESS 411 EAST CRESCENT PL CHANDLER AZ 85249 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO ID 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 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER 1 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 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 John Gilmore LICENSE# 13699 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: PLEASANT BAY PLUMBING INC. ADDRESS. 43 B Independence Way, CITY Brewster STATE MA ZIP 02631 TEL FAX CELL EMAIL pleasantbayplumbingAcomcast.net 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 ,.k(70 ..1_%,. MA$SACHUSETTS UNFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK = xq •` -. CITY 1�M‘,k^ MA DATE lik (r,--11--° PERMIT# G G•ai- Oa 2,9 GJOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESlDENTIAL,t PRINT CLEARLY NEW:❑ RENOVATION REPLACEMENT:0 PLANS SUBMITTED: YE&J NO 0 APPLIANCES Z RLOORS-► BM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ) j 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 I SPACE HEATER r , ROOF TOP UNIT TEST , _ UNIT HEATER r UNVENTED ROOM HEATER a WATER NEATER • , grit, t c OTHER f t INSURANCE COVERAGE I have a aunent lishilibt insurance poky or its substantial equivalent which meets the requirements of MGI_Ch.142 YES_NO 0 IIF YOU CiEC1WD YES,PLEASE INDICATE THE TYPE OF COVERAGE BY O ECIMG THE APPROPRRATE BOX BELOW LIABILITY ANCEPOucTZ`J-., OTtERTYPE 111DEIWTY 0 BOND ❑ OOI!lIER°S INSURANCE WAIVER 1 alts asenelhatthe icawee does notion the insurance coverage required by Chapter 142 of the Massachusees Genesi Laem,and t attey signature on this per application drives this requirement CHECK ONE ONLY: MINER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I haw submitted or entered regarding this application are true- . . to the best of my knowledge and that all plumbing work and installations perfomned under the permit issued for this applir don v be in..-.;• r' , _. provision of the Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws. �l�• r� .1611.4 PLUMBER-GASP'i rut NAME LICENSE 8( .0.??. ` lir 'TURE MP MGF 0 JP❑ JGFLPGI�r CORPORATION❑# PAR-DE-RSV❑# LLC❑# COMPANY NAME-n s 6' t.r. ADDRESS 3k1 we0-)C6-- W f1/4-(.. - CITY iCITY lle-r s STATE\VA- 7,�-C 3( TEL ? Z LC-?Z e'ASV' FAX CELL EMAIL