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HomeMy WebLinkAboutBldp-21-007321 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I MA DATE June 16,2021 PERMIT# BLDG-21-007321 CITY IYARMOUTH JOBSITE ADDRESS 117 PEREGRINE LN OWNER'S NAME 'BURKE CHRISTOPHER J G OWNER ADDRESS BURKE JUDITH M 14 KIMBALL AVE WAKEFIELD MA 01880 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 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 1 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 'Andrew Leighton LICENSE# 116130 SIGNATURE MP© MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: 'ANDREW R LEIGHTON ADDRESS. 120 Brewster Rd, CITY 1W Yarmouth STATE MA ZIP 026735706 TEL ' FAX I 1 CELL I I EMAIL Ihalloilcompany@gmail.com r -,9 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 0 —,. _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FIT77NG WORM — Y V W1 DATE /3/-4/ PERFAT#8i06-1i-vo-77�1 JOBsrrEADDRESS 1? PeR ear rive 1/9. -OWNEWS NAME C k r 15 13 v r l4 p G OWNER ADDRESS /'r • • f TYPE OR . . - TELL IP' /P`�"S` p FpJC PRINT OCCUPANCY TYPE COMMERCIAL EDUCA s RESIDENTIAL / CLEARLY NEW: /RENOVATION: REPLACEMENT: • PLANS SUBMITTED: YES NO L APPLIANCES 2- FLOORS-• BS14 1 1 21 3 4 5 5 7 l 8 9 10 11 12 1 13 BOILER BOOSTER _ — . I - 1 . CONVERSION BURNER I I - COOK STOVE _. I • DIRECT VENT HEATER I _ DRYER . FIREPLACE ;�( I I FRYOLATOR — FURNACE • _ . . . .-....:( I GENERATOR • " GRILLE - - INFRARED HEATER LABORATORYCOCKS - • - MAKEUP AIR UNIT • . - - OVEN r POOL HEATER ' ROOM/SPACE HEATER - - • . - «4 ROOF TOP UNIT TEST :x - _ war HEATER UNVENTED ROOM HEATER _ . WATER HEATER - _ . -' OTHER - - INSURANCE COVERACE I have a current Itabiil +insurance policy or Its substantial equivalent which meets the requkaments of YGL.Ch.142 YES 1'NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING TIE APPROPRIATE BOX MOW LIABILITY INSURANCE POLICY ✓ OTHER TYPE @AMENITY BOND - OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have Bar Intarrance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application maim this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE •> OWNER AGENT I hereby certify that an cute dads and hicameion I have submitted or entered regarding this era. . ._ ledg and that en omitting work and ro om postmenunder the Rates i fertile w2f be In•.., "'"f - 01'. Kntae Massachusetts StateP! ~_ ,,t:;�_- •_u,..,. Of the IstlbhxJ Code and 142 oftlte G L.awe. • �- PLUMBER-GASH i I tit NAME ANDREWWt? LEIGHTON - LICENSE* 1613044 - SIGNATURE MP • MGF JP JGF LPGI CORPORATION r # 3734C PARTNERSHIP # COMPANY NAME HALL OIL COMPANY INC. LLC # ADDRESS 435 RT 134 CITY SOUTH DENNIS STATE MA ZIP 012660 . FAX 508-�s43c168TEL 508-308-3831 CELL EMAIL m