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HomeMy WebLinkAboutBLDG-21-002576 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE November 05,202( PERMIT# BLDG-21-002576 tip s � JOBSITE ADDRESS 939 ROUTE 6A UNIT B2 OWNERS NAME GEORGE THOMAS N TRS G OWNER ADDRESS T A C REALTY TRUST 17 THACHER SHORE RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL Ell PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 • 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ 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 LICENSE# SIGNATURE MP❑ MGF ❑ JP❑ JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: KiL-S Cry ADDRESS. CITY STATE ZIP TEL FAX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tcv CITY YARMOUTH I_f - MA DATE November 05,202( PERMIT# BLDG-21-002576 JOBSITE ADDRESS 939 ROUTE 6A UNIT B2 G OWNER'S NAME GEORGE THOMAS N TRS OWNER ADDRESS T A C REALTY TRUST 17 THACHER SHORE RD YARMOUTH PORT MA 02675 TYPE OR OCCUPANCY TYPE TEL PRINT TEL ❑ RESIDENTIAL Ej FIXTURESCLEARLY NEW: 000RS El REPLACEMENT: PLANS SUBMITTED: YES 0 NO 0 BSM 1 2 3 4 5_ 6 7 8 9 10 11 12 13 1131 BOILER BOOSTER - CONVERSION BURNER - DOOC STOVE _ - DIRECT VENT HEATER _ _ ___ - VENT DRYER - FIREPLACE _ _ - FRYOLATOR _ - FURNACE - GENERATOR - GRILLE - INFRARED HEATER - LABORATORY COCKS - MAKEUPKEUP AIR UNIT - OVEN all - POOL HEATER _ _ _ ROOM/SPACE HEATER - ROOF TOP UNIT - TEST 1 - UNIT HEATER - UNVENTED ROOM HEATER - WATER HEATER _ - OTHER - OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current lial__2i&insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW YES ❑ NO❑ 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 Ma General Laws,and that my signature on this permit application waives this requirement. ssachusetts 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 MP El MGF LICENSE# SIGNATURE ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# - PARTNERSHIP 0# LLC COMPANY NAME: El#� ADDRESS. CITY FAX STATE L ZIP �TEL CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No C9� ! !j l 3 /Z.zrzci c S THIS APPLICATION SERVES AS THE PERMIT ❑ El FEE: $ PERMIT# PLAN REVIEW NOTES