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HomeMy WebLinkAboutBLDG-21-006761 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 5' CITY (YARMOUTH MA DATE May 21,2021 PERMIT# BLDG-21-006761 JOBSITE ADDRESS 1321 PINE ST OWNER'S NAME BREESE PROPERTIES LLC G OWNER ADDRESS 1411 EAST CRESCENT PL CHANDLER AZ 85249 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ 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/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 11 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❑ LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: PLEASANT BAY PLUMBING INC I ADDRESS. I CITY IBREWSTER I STATE MA ZIP 02631 TEL FAX CELL EMAIL PLEASNTBAYPLUMBING@COMCAST.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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK W/ CITY ,/-.tip--��K`C"\ MA DATE S/!j/d l PERMIT# JOBSITE ADDRESS Z k V, OWNER'S NAME c 1E- \ T \ ` L GOWNER ADDRESS f C.��� ( 1-C> _f4 0\oK E TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIALI PRINT CLEARLY NEW: ❑ RENOVATION:, , REPLACEMENT:❑ PLANS SUBMITTED: YES4 NO❑ APPLIANCES 1 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 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 • OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 4_NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY El BOND El 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 ❑ AGENT ❑ 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 cur . be df my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi a`tI P ..ro ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ;CSE ` ���` �� LICENSE# k rC( SIGNATURE MPg_ MGF El JP El JGF❑ LPG!El CORPORATIONO#"-(c'{Ce PARTNERSHIP❑# LLC❑# COMPANY NAME E:•� � 1 �` �,'1��` `' - C . ADDRESS `I C3 c{, ti=`- [ CITY �2 < : �2 STATE V1" 7 ZIP C' �. _ TEL 7 `-( !� 1 �' CELL EMAIL \�--R` t\t,A`t '��:��� ^�„k�C�`� `� C. �',6r t FAX i