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HomeMy WebLinkAboutBLDG-21-007322 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,, CITY YARMOUTH MA DATE June 16,2021 PERMIT# BLDG-21-007322 Ii_ JOBSITE ADDRESS 122 THACHER SHORE RD OWNER'S NAME BASSICK JOHN W G OWNER ADDRESS BASSICK SUSAN M 65 MARSHALL ST PAXTON MA 01612-1233 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:0 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 DIRECT VENT HEATER DRYER FIREPLACE 1 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 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 1 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 Andrew Leighton LICENSE# 16130 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: ANDREW R LEIGHTON ADDRESS. 20 Brewster Rd, CITY W Yarmouth STATE MA ZIP 026735706 TEL FAX CELL EMAIL halloilcompanyc gmail.com a ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE:$ PERMIT# PLAN REVIEW NOTES N rt0e, CX' — '-= MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK it - CITY A I t�+o� r rc�'� MA DATE rr f-5/1' PERMIT#13L C6-2(-00-7 318 JOBSITE ADDRESS I.X 2 T11 Mi+c L-N S'Lr c$ p -OWNER'S NAME SA 04. $ASS tC t GOWNER ADDRESS R r '' TELScr-S,15-9'0/0 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDE/MAL 1,1 CLEARLY NEW:/' RENOVATION: REPLACEMENT: - PLANS SUBMITTED: YES NO V APPLIANCES Z FLOORS-4 BSM 1 1 2 I 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER - - CONVERSION BURNER } COOK STOVE . _ DIRECT VENT HEATER DRYER . . - FIREPLACE I FRYOLATOR . ^ FURNACE ( .. I - - - - GENERATOR f • ' GRILLE INFRARED HEATER ' LABORATORY COCKS - MAKEUP AIR UNIT ' - - OVEN _ , e POOL HEATER — ROOM!SPACE HEATER _ > : _ _._ ROOF TOP UNIT • TEST r 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 i/NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V OTHER TYPE lNDE11NfTY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage raquirad by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK SIGNATURE OF OWNER OR AGENT ONE• OWNER AGENT I hey certify that a0 of the details and Warmth=I have s tded or antersed reganSna tits are• and, of my Knowledge and that an ply work and mammalian for the Massachusetts Stats Plumbing Code and Chapter 142 of the General Laws. •win be IFI«• ,,/iA.�j41.•-i,,,•, of the PLUMBER-GASFITI'ER NAME ANDREW LEIGHTON UCENSE ft 16130.4 M SIGNATURE TURE MP ' IMF JP JGF LPGI CORPORATION I # 3734C PARTNERSHIP COMPANY NAME HALL OIL COMPANY INC. LLC # ADDRESS 435 RT 134 CITY SOUTH DENNIS STATE MA ZIP 02880 TEL 508-398-3831 FAX 508-3943068 CELL EMAIL ha8cyegmetcam