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HomeMy WebLinkAboutBldg-22-002149 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK X •C' BLDG 22 002149 e CITY YARMOUTH MA DATE October 14,2021 PERMIT# r' �v JOBSITE ADDRESS 9 NIGHTINGALE DR OWNER'S NAME LAUGHTON ARTHUR A G OWNER ADDRESS 9 NIGHTINGALE DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 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 Robert Brodie LICENSE# 30565 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPG! 0 CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: ROBERT D BRODIE ADDRESS. 184 VILLAGE LN, CITY WELLFLEET STATE MA ZIP 026678119 TEL FAX CELL EMAIL none ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El El FEE: $ PERMIT# PLAN REVIEW NOTES --R MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _ �e� ) 2 i4 .z�ITY gv-c r�az(' MA DATE /0//'7/12 f PERMIT# ZZ 9 I 2 cc hOBSI E ADDRESS q /l/1 ,,r f Or OWNER'S NAME �1 i.�ZL 0-t-I s ;OWNER ADDRESS ' . TEL /FAX WI' YP> tt o !OCCUPANCY.TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ V P T' 1z LI JILE ° NEW:i& RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPI IANCFS 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 'I3 14 BOILER t BOOSTER j CONVERSION BURNER COOK STOVE / _ DIRECT VENT HEATER DRYER, ' _ i FIREPLACE FRYOLATOR l FURNACE GENERATOR GRILLE i INFRARED HEATER I LABORATORY COCKS • i MAKEUP AIR UNIT 1OVEN �� POOL HEATER ROOM I 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 YE at NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE FOLIC' OTHER TYPE 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT -1, 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 I` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE tr50S052— SIGNATURE MP❑ MGF❑ JP k JGF❑ LPGI ❑ CORPORATION❑0 PARTNr 'HIP❑# LLC❑# COMPANY NAME C . v�e./-10\/t9ck.y0 ADDRESS7, 0 O . -7 7' /� n CITY L'(� , �i,J eq.,' STATE //l if, ZIP 0.Z 6 7 I TEL X �•3,1C3- Z 93 FAX CELL EMAIL • ' 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