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HomeMy WebLinkAboutBldg-22-002179 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tii - 7" CITY YARMOUTH MA DATE October 17,2021 PERMIT# BLDG 22-002179 JOBSITE ADDRESS 33 MAINE AVE OWNER'S NAME BROWN ELAINE TR G OWNER ADDRESS THE 33 MAINE AVE NOMINEE TRUST 58 MCSHANE AVE GREENLAND NH 03840 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 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/SPACE HEATER i ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 ❑ 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 Charles Stockdale LICENSE# MA SIGNATURE MP❑ MGF ❑ JP❑ JGF 0 LPG( 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: ICLS Plumbing I ADDRESS. 1256 Mayfair Rd., CITY (South Dennis STATE MA ZIP 02660 TEL 15083981196 FAX CELL 7742081613 EMAIL 1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTQR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES