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HomeMy WebLinkAboutBLDG-21-006909 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK(itimilM CITY YARMOUTH MA DATE May 28,2021 ]PERMIT# BLDG-21-006909 JOBSITE ADDRESS 277 ROUTE 6A OWNER'S NAME Baxter Yarmouthport Holdings Ilc G OWNER ADDRESS 277 MAIN ST YARMOUTH PORT MA 02675-1817 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ 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 ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:outdoor firepit 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 James Parkhurst LICENSE# 13223 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: JAMES P PARKHURST ADDRESS. PO BOX 6273, CITY Plymouth STATE MA ZIP 023626273 TEL FAX CELL EMAIL Iparky317Ryahoo.com 7- - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,,_,.. . t„... CITY y‹,,,,,, ,,,,i4.1 MA DATE '. .„ PERMIT# JOBSITE ADDRESS___ 1 7 7 �o a¢ OWNER'S NAME t./ f-, I / G /�N OWNER ADDRESS C� -L4 r 1/ TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL g EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:id REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO ❑ APPLIANCES 1 FLOORS— BSM 1 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 OU¢-ri d D r-, t ' FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER I LABORATORY COCKS I MAKEUP AIR UNIT OVEN POOL HEATER ROOM SPACE HEATER ROOF TOP UNIT 1 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 YES0 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVEyGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a 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 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia •th a rtinent ien of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER ASFITTER NAME LICENSE# / ,)r7 a 3 SIGNATURE MP MGF❑ JP JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME !�`'I J �4 ADDRESS 0 5' Ca i 7"3 s CITYPyii711 STATE .ii- ZIP D, 3 & 2 TELFAX CELL EMAIL 6 1 tzy 3 17 e C 4, .G‘iti-(._