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HomeMy WebLinkAboutBLDG-21-006421 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK = CITY YARMOUTH MA DATE May 06,2021 PERMIT# BLDG-21-006421 fr e JOBSITE ADDRESS 1069 GREAT ISLAND RD OWNER'S NAME NOLEN WILSON G OWNER ADDRESS 1120 5TH AVE APT 10B NEW YORK NY 10128-0144 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Ej PRINT 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 1 DIRECT VENT HEATER DRYER 1 FIREPLACE 1 FRYOLATOR FURNACE 2 1 • GENERATOR 1 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 2 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 William Woods LICENSE# 11887 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: WILLIAM T WOODS ADDRESS. PO BOX 702, CITY W BARNSTABLE STATE MA ZIP 026680702 TEL FAX CELL EMAIL $/130 ` " MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK n, �1 CITY --/97eG ela _ U(/ . .. . ! MA DATE S `5 v2I `(PERMIT# BC DC�-11-vc,6 H L( JOBSITE ADDRESS? 6,-7-�S-N 16411 OWNER'S NAME ^ '-d-AE - ---1 GOWNER ADDRESS " — '_T ---, - _ ! 'G �j� 7SI TEL j FAX =- I TYPE OR OCCUPANC E COMMERCIAL;,_] EDUCATIONAL PRINT _j RESIDENTIAL' CLEARLY NEW:'._ RENOVATION:__I REPLACEMENT: PLANS SUBMITTED: YES N0+ . APPLIANCES 7 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _—I . 1__I J___1 1._-_I_J__I_J`_I_1 . t__._1__J BOOSTER --!. I I; I t_____I____I.-____J______I__I___I_. 1___t CONVERSION BURNER COOK STOVE I I— I l I-- i __I_____I____I__I____1 .1—J --1 /. I ___.I___I_-_J__.I_I_._I____1_ _!_-I DIRECT VENT HEATER .__1 I._�__I_ I_�_J____I —�-J______IDRYER• :_.I 1 I_J_ .. l J ._ ..I_ I II I I , FIREPLACE ( I I. I__J�1 J ,____I . - 1 i_�_J I FIREP FIREPLACE -- . - -- , _� _ I. 1. I 1 I I _ I _ I .1__I FURNACE UR RCEOR a I ___ 1 1 1 I_� I r I —_i___I I : GRILLE 3 11 _1_ __J_J l_-_____.1.___I_.___J._-_J INFRARED HEATER ___I—I I.—J- I I ...._ E-) I_1 -J_ J_.J_I jib LABORATORY COCKS - MAKEUP AIR UNIT Ilk OVEN ._ .1 I f 1 ; 1._ I'______I I I i Ilk POOL HEATER ""`�_ 1 I ----I I I__.__J__I _ .J ROOM/SPACE HEATER I - !` I I i _� 1 e_ - r--- _____I___J r_I ROOF TOP UNIT .___ W _.- { -_.___;_--- ---- -1-----I _._ ( I I TEST . ' - •_ - ! �i I I---1 i e-1 ____II ?__ __'- --`` I : i— I I i UNIT HEATER UNVENTED ROOM HEATER _i__1 i ;_J _J I__j 1 I - I i WATER HEATER. . .. --- I . .. . I OTHER , _. I I t 1 _ • J • # I I ___I I 1 i . l 1 - .�_1 ? ___J _-__._J 1__-.! 1 I —( i I � , l lit I, 1 1 1 I - 1 1 -_-!._._.._I�_ t' z ,.._ I._____! i INSURANCE COVERAGE tI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I E NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY . BOND Li 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 :',_,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 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��s�� PLUMBER-G SFITTER NAME:'/�' awls I LICE#ll a?71 SIGN E MP W MGF 2J JP Li JGF ' LPGI CORPORATION PARTNERSHIP I# - LLC # - COMPANY NAME ,P1�S' -- G� _ —I ADDRESS �U ._.--- P I 7 CITY 1 - . , STATE 1•l`¢-121P O?(6I TEL -56� JJ-`� 3 FAX I CELL;, 3(S0 I EMAIL aas!A ,cots 71-, ' J