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Home My WebLink AboutBLDG-21-005480 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ?5. CITY YAR_MOUTH MA DATE March 23,2021 PERMIT# BLDG 21 005480 Li JOBSITE ADDRESS 964 ROUTE 6A OWNER'S NAME john nash G OWNER ADDRESS 964 ROUTE 6A YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL III 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 1 POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 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 El 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 LICENSE# 34056 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: THEO PLUMBING AND HEATING LLC ADDRESS. P.O.Box 397,P.O.Box 397 CITY Centerville STATE MA ZIP 02632 TEL FAX CELL EMAIL theoplumbinq@yahoo.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE:$ PERMIT# PLAN REVIEW NOTES ILI, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =T11 CITY: _ _�, r�• pc MA. DATE: ."- /) Z Z G j I PERMIT# JOBSITE ADDRESS: �� ) tO OWNER'S NAME: TO' 1''M 1V el c GOWNER ADDRESS: c\( 1(2 T TEL: c. 1• ) ( V -4c FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:El RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCESI FLOOR-, Bsmt 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 eu LABORATORY COCK MAKEUP AIR UNIT r OVEN POOL HEATER ROOM/SPACE HEATER -J ROOF TOP UNIT ' TEST .. UNIT HEATER .i.j UNVENTED ROOM HEATER j WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YESO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. ' LIABILITY INSURANCE POLICY Cl OTHER TYPE INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER: lam 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 0 AGENT Cl SIGNATURE OF OWNER OR 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-oeisplia9ce with all Pertinent provision of the Massachusetts State,Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: 7 '' 'a G LICENSE# 3t16c6 _ SIGNATURE COMPANY NAME: \ t.r Z v ')kJ r✓ 4'4Y qeDiSlitc,`� �•C 6�j d � Cl ,� CITY. ( �,"‘ f,i ) 1t� � - ``�� 1 STATE: 0 ZIP: 2 4. 3L FAX: �� TEL: ct 4�j 1 " CELL: ( Al-11 & i-,o EMAIL: ��✓ '� � ._ � .ti---• MASTER❑ JOURNEYMAN LP INSTALLER ❑ CORPORATION❑# PARTNERSHIP ❑# tic ( 60 ( 3 r111 E h7/)-i L .DDrz -SS