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HomeMy WebLinkAboutBLDG-22-000764 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Z CITY YARMOUTH MA DATE August 10,2021 PERMIT# BLDG-22-000764 JOBSITE ADDRESS 21 TRUMAN LN OWNER'S NAME DONAIS JEFFREY A G OWNER ADDRESS DONAIS MARGARET E 56 RIDGE RD SOUTH HADLEY MA 01075 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ID 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 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 0 OTHER OF INDEMNITY 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 (Andrew Leighton LICENSE# 116130 1 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPG( 0 CORPORATION 0#I PARTNERSHIP 0# LLC ❑# COMPANY NAME: ANDREW R LEIGHTON ADDRESS. 120 Brewster Rd, CITY W Yarmouth STATE MA ZIP 1026735706 TEL FAX 1 'CELL 1 EMAIL Ihalloilcompanv@amail.com 1 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 UhliFORW APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK r_ __ rI yii9R �J 4��—y.� cmt GG£� • �v°7-',�/ MA DATE ..g/1/,'1 PERMtT# CZ- - "1�� JOBSITE ADDRESS 2/ T/w A-1 A-At 1/9 _4WNER`S NAME pJ d 1�i 9,9 i S _ OWNER ADDRESS /f TEL Y/3-53/- V5-23 FAX TYPE PRINTOOCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: aRENOVAT1ON_ R> L&CEMEN : PLANS SUBMITTED: YES NO 1l AP L IA CES 1 FLOORS-, I Um i 1 2 I 3 4 5 } 8 7 8 i 910 11 12 13 14 .sf i BOOSTER : t • CONVERSION BURNER _ COOK STOVE -1-71 � I , • DIRECT VENT HEATER ( _ _ ! } I } DRYER I ! 1 1 1 ! FIREPLACE ( } } } I _ I FRYOLATOR ( --_ }. _. i _ .. - f I -__ - - FURNACE k ( I GENERATOR GRILLE _} i . i } .� INFRARED HEATER } } •_ - - - LABORATORY COCKS . .I . . l - _} MAKEUP AIR UNIT } - - OVENI ( __ I { - POOL HEATER i 1 € ? _ . .1 1 .----,-1 . _ ROOM I SPACE HEATER 4 ( . } ( I I - -— ROOF TOP UNIT ( I } I. • _ } I }} UNITEATER I { i _ UNVENTED ROOM HEATER } I I . r WATER HEATER } } _ ( I I . . - - _ - OTHER } } } 1 - - • INSURANCE COVERA e- I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1/NO i IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE '-OPRIATE BOX BELOW LIABILITY INSURkNCE POLICY V OTHER -=INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the' - ce coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application . --this requirement. CHECK ONE 0 : OWNER AGENT SIGNATURE OF OWNER OR AGENT l I hereby cer fy that all ai the details and tnfo� icn I have submitted or entered rege no are and ! , •- yr my Knowledge and that all plumtm�work and 1nsmuasone perfcrmcd anterttte permit Issued for this app n;a91 be in pIIart /i.' -J;, c,�;: .. of the MassechuseUs State Pit abing Code and Chapter 142 of the General Laws. "- PLUMBER-GASFITrER NAME ANDREW LEIGHTON LICENSE 18130-M 1111wr SIGNATURE MP + MGF JP JGF I.PGi CORPORATION f T 3734C PARTNERSHIP # LLC COMPANY NAME HALL OIL COMPANY INC. TION SS 435 RT t CITY SOUTH DENNIS STATE MA ZIP TEL 508-398-3831 FAX 508-394-3058 CELL TAIL ha Iolcomparty(a39mail.corn