HomeMy WebLinkAboutBLDG-23-005330 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
; 7of CITY 'YARMOUTH I MA DATE (March 29,2023 I PERMIT# BLDG-23-005330
JOBSITE ADDRESS 157 GENERAL LAWRENCE RD I OWNER'S NAME (FELLS MARYANN
G OWNER ADDRESS IEPPICH SALLY J 57 GENERAL LAWRENCE RD SOUTH YARMOUTH MA 02664 I TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL
PRINT ❑ RESIDENTIAL El
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0
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
ROOF TOP UNIT
TEST 1
UNIT HEATER 1
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 ID 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 (Tyler Bagge I LICENSE# 126559
MP ElMGF❑ JP ElJGF❑ LPG' El
CORPORATION❑#I�J ( SIGNATURE
PARTNERSHIP ❑#I ILLC ❑#
COMPANY NAME: ITYLER BAGGE
I ADDRESS. PO BOX 2000,
CITY SOUTH DENNIS STATE MA ZIP 026601613 TEL
FAX 1 1 CELL EMAIL baggepipinqyahoo.com
� hIt,4SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO
�r., PERFORM GAS FITTING WORK
P
IAA DATE 3',. -7 -�3
JOESITE ADDRESS �7 �� # � PERMIT tr L� - S 33d
OWNER'S N.AME /T�vy,� jy/,�
OWNER ADDRESS /S�'a,
TYPE OF TEL FAX
PRINT OCCUPANCY TYPE COMMERCIAL❑ �DU„r
CLEARLYCLEARLYATION4L ❑ RESIDENTIAL ID
NEW: IC4 RENOVATION:0 REPLACEMENT:0
APPLIANCES 7 PLANS SUBMITTED: YES❑ NO 0
BOILER FLOORS-� SEN vaa •'� y
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BOOSTER mini-- �--
CONVERSIOIV BURNEP,
COOK STOVE ni��
DIRECT VENT HEATERall �-
DRYER �= mini-- =�-
FIREPLACE all.
—= _ -
FRYOLATOR MEIN
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GE ---�— _ _
GRILLE _�=�_ -
INFRARED HEATER _-
LABORATORY COCKS aallll _lill� =- _
MAKEUP AIR UNIT szamilimminimi -__- mini_
POOL HEATER -��_-_==� _-
ROOL I SPACE HEATER -_-�� Imminnum-�
ROOF TOP UNIT _--�- _
uNIT ®®®®®
_NrUNVENTED ROOM HEATER === �maimr. ....„.„
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OTHER
=�_ _
mini_-111111 ==- =-
I have a current Ilabili insurance policyURACOVERAGE
or its substantial equivalent which meets the requirements of MGL.Ch.142 YES
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOXNG O
' LIABILITY INSURANCE POLICY BELOW
OWNER'S• INSURANCE WAIVER:I am aware that the!i�a does not Ohave�TYPE INDEMNITY ❑ BOfUI3
Massachusetts General Laws,and that my signature on this permit application 0
the insurance coverage required by Chapter 142 of the
pp waives this requireirrettt.
.� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER
I hereby certify that all of the details and information I have submitted or entered regarding ❑ AGENT 0
and that all plumbing work and Installations performed under the permit issued for this application will be in compliance
Massachusetts State Plumbingg 9 this application are true and accurate to the best of my knowledge
LEI Code and Chapter 142 of the General Laws. p►ance
PLUMBER-GASFITTER NAME "t r n of the
MP 0 MGF❑ JP LICENSE#...?(P S-7 'IGNATU
6 JGF)11111 LPGI ❑ CORPORATION❑
COMPANY NAME 7 PARTNERSHIP 0# LLC #
e r i I/ / /7/ ADDRESS 3 3 ❑
CITY ,mow.
STATE 292_&_ ZIP Doj 42-
FAX �pr_ TEL
FA
CELL �7y d _� n EMAIL f4