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HomeMy WebLinkAboutBLDG-21-005013 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Frig 144, CITY YARMOUTH MA DATE March 05,2021 PERMIT# BLDG-21-005013 `� JOBSITE ADDRESS 620 ROUTE 6A OWNER'S NAME BASS RIVER ROD&GUN CLUB INC G OWNER ADDRESS 620 ROUTE 6A YARMOUTH PORT MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 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 1 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 2 . 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 0 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 Barry Gremila LICENSE# 10244 SIGNATURE MP© MGF 0 JP❑ JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: BARRY R GREMILA ADDRESS. PO BOX 1025, CITY NORTH EASTHAM STATE MA ZIP 026511025 TEL FAX CELL 5082373878 I EMAIL none MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: VI kW)v MA. DATE PERMIT# DG Z 1- C0O 5013 G JOBSITE ADDRESS: h AC7yV�� 1f 6i V/(vi4aApov.k OWNER'S NAME: OWNER ADDRESS: v1- Z j'— {Z)d / l'3t J,-t TEL: )h "1)4- `3 Z FAX: TYPE OR PRINT OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ CLEARLY NEW:El/ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO ge- APPLIANCES-. FLOOR-4 Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER f DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE IA INFRARED HEATER e LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER } ROOF TOP UNIT TEST UNIT HEATER 11.1 UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES dNO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY El/ 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT ❑ 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 ail Pertinent provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. _ PLUMBER/GASFITTER NAME V> (pit?vt4 J - LICENSE# /()ALI SIGNATURE COMPANY NAME: N}ui 411 t- ' 0.2,,43 14 ADDRESS: 1 s� r'2 2,-‹ CITY:�(. v\-ck 14,1 SATE: IM ZIP: 0 ALF s FAX: TEL: 5-4, - �5 � 3 �� . CELL: ,���`�;���-�J� EMAIL: alf JOURNEYMAN❑ LP INSTALLER❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# L.. h t}>t.. 1)Ditee ss ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No '261`J4 o,` >1 ` , ^'`' THIS APPLICATION SERVES AS THE PERMIT El El FEE:$ PERMIT# PLAN REVIEW NOTES