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HomeMy WebLinkAboutBldg-22-001582/ w MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w BLDG-22-001582 CITY YARMOUTH MA DATE September 20,202 PERMIT# t ‘4,4„. JOBSITE ADDRESS 7 MAINE AVE OWNER'S NAME PERLOV ANATOLY EST OF G OWNER ADDRESS 59 BRAINERD RD APT 507 ALLSTON MA 02134 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 12 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ 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 , FRYOLATOR , FURNACE , GENERATOR , GRILLE , INFRARED HEATER , LABORATORY COCKS , MAKEUP AIR UNIT , OVEN , POOL HEATER , ROOM I 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 0 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 Dennis Gagne LICENSE# 9804 SIGNATURE MP© MGF 0 JP 0 JGF 0 LPG! ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: 'DENNIS M GAGNE ADDRESS. 31 Cherrvwood Ln, CITY IMarstons Mills STATE MA ZIP 026481761 TEL FAX I I CELL I EMAIL Igagneamq51ta7.aol.com ti S310N M3IA32i NYld —� #1IV fJd $ :33d ❑ ❑ II1A1a3d 3H1 Sd S3A213S NOLLY3IlddV SIHl oN saA S310N NOI103dSNI 1VNId AlNO 3Sl 210103dSNl 210d 39Vd SIHI S310N NOI103dSNI SV9 HJf102i +r•t 17S, CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK „ ... fin .;, iNT CI,I.�,.._._ cirl.o' . ..t_ t l i MA DATE I PERMIT# ? 7- 15'$ - QJ 1TE D SS`^5 - A fi.�e F . &. 4 R l OWNER'S NAME ` I►-- e- -1 \ IL-_0 R:SS i TEL 74 1 • FAX „TYPE OR--_ _ - - -- • 1 T • L JPAPTUY TYPE COMMERCIAL;-�.( EDUCATIONAL j RESIDENTIAL' CLEARLY NEW:, RENOVATION:13 REPLACEMENT:^I PLANS SUBMITTED: YES E D NOD APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _J—__.J_J- II J_J J. I—1_J_ I . I. - I _. I BOOSTER - .. I .__ CONVERSION BURNER TJ,:_i_J—J—_1 I-__ _J,!__J—J—J— i___I—J��`_� COOK STOVE I— __t'_1_J._1_. 1.—J:�___ J.'_ __J I _- ! DIRECT VENT HEATER DRYER _ J _J L—J-i I_I_ . I'__I.- .- -. i I � i_ FIREPLACE I I _ , J__ .-€I _I._ ��- J . I _-I. I—J FRYOLATOR I—J'—J:� _ _ . ___-__I_—I I 1 _...:__1 - -- I—.1—1 FURNACE _1—J-_j. I__I 1 1_J_J I-_I__.__J._.-_1_1 I GENERATOR I I: - - I I �I ---I 1____J_____I_J�J I—J GRILLE _J, I I 1__I I __ :�J°__!-_____I_ J _____I_____I___( __J INFRARED HEATER _J - J_J___I 1 �I'-1 —1 _I_____J'_____I_—_I . ___I- LABORATORY COCKS I i.._._J' _.___1_-__-___-_,I1 I.____I r._J_____i __I-_ _1_I�1 i MAKEUP AIR UNIT ` ...._ 1:_—I_—J_J f .. I_—J____J _1, I_—I_____ : I OVEN _—.I 1____I,_J`__1__-_J 1_J__._.J'_._ I_! _�I___.J i4. POOL HEATER _.J___I:�J__I,__I I __ - __.__I ____1.____I—I_—I____I ROOM/SPACE HEATER _ _I . .:.1_ �.I I I ....1 . ROOF TOP UNIT .{1 I I_J I 1___. (____,..1 J I__J __J�j_____1__J TEST t✓' -I I I J 1 _ �.I I I I......_.1I UNIT HEATER 1_.._.! I i :t____I __I J_ � �_J:_J I I__J _._UNVENTED ROOM HEATER J I .� I I _Li,_,___I L J I____J_1_1_J____1 WATER HEATER. _ ___ -__ _; I- I _ 1__I j____J_1.-.__._J_.J___J I '___J—_J__I OTHER I__.1 1' 1____1 I:_ I_I I J______I__J.__ 1._J I—I • 1__.___.J--_-_-_::_1 I_-1 1.,___.1___.1____1.__._I I __=J_J'.__I__J _._ J 1_.__.I-I 1 - ' I__1 1_i_____J __1 _I I I_. . ..1 1 — ! I I I, I_....__I 1__-J 1. .. J 1 I 1,. i tINSURANCE COVERAGE z I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES e'NO _ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY !. OTHER TYPE INDEMNITY II] BOND 1_1 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 7 i AGENT :_1 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 fine, i! ,r/� y�I LICENSE#'W per 14} SIGNA-* MP MGF Li JP JGF A LPGI J. CORPORATION #'3Z3'J [PARTNERSHIP:1.# LLC:_[# COMPANY NAME:afi re/is�`T ' e I ADDRESS ft.-K.746V - - — -- - — CITY /.. 74$e ?64 I STATE/IP( I ZIP O7 7 7 !TEL 777/=�3i•-a? -1. FAX I CELL. [EMAIL` (ice-,', /64.5/ ,get, &Ili - - ..---.._- .-__._.__..r ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 El FEE: $ PERMIT# I'LAN REVIEW NOTES • 103V3 V:4 iltA4 VS ce 4