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HomeMy WebLinkAboutBLDG-22-003184 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 'December 06,2021 PERMIT# BLDG-22-003184 JOBSITE ADDRESS 129 FOREST GATE VILLAGE ]OWNER'S NAME Lynn Gorey G OWNER ADDRESS 29 FOREST GATE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID 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 1 _ 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 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 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 thereby 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 'Dean Farnham !LICENSE E 113203 I SIGNATURE MP©MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: (DEAN P FARNHAM ADDRESS. '6 WILLOW WAY, CITY 'SOUTH DENNIS 'STATE MA ZIP 1026603060 I TEL FAX I I CELL I 1 EMAIL Ideanfarnham56na-gmail.com S310N AADA38 NVId #11w�13d $ :33d ❑ ❑ IIWM3d 31-11 SV S3A213S N011VOIlddV SIHL oN saA S310N N01103dSNI 1VNId ,llNO 3Sfl H0103dSNl NOd 9 Vd SIH1 S310N NO1103dSNI SVO HJflOb r ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r :7s 4; -� .6" CITY 4 s'.-c`,.( U- ; liar, DATE lA - o? >* PERIv11T# ZZ JOSSITE ADDRESS .2 `Or ems- ()< r OWNERS NAME e-y/1/1 `=CJ/ cX GOWNER.ADDRESS TEL FAX TYPE OR PRIN OCCUPANCY TYPE COMMERCIAL❑ ED C IC I41 ' iE I�lTIAL{� CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT ----_,__ Id RAI S SUBMITTED: YES❑ NO❑ DEC,_0 2 2(121 APPLIANCES I FLOORS-4 BEM 1 2 3 1 6 , J 9 10 11 12 BOILER is14 BOO�,rTER BUILDING UEFA;TAIL-N� --_____ CONVERSION BURNER COOK STOVE —�_ DIRECT VENT HEATER ' DRYER FIREPLACE FRY CiLATOR FURNACE GENERATOR GRILLE INFRARED HEATER —_, LABORATORYCOCKS , , MAKEUP AIR UNIT • OVEN POOL HEATER ROOM;SPACE HEATER , __ ROOF TOP UNIT TEST . UNIT HEATERt. ___ 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 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2 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. i. 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 a accurate to the best of m and that all plumbing work and installations performed under the permit issued for this application will be in oomphce with all 'ne ,rovision n the dge Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Lij C. PLUMBE -GASFITTER NAME LICENSE# (3 0-1 SIGNATURE MP MGF JP ❑ ❑ JGF❑ LPGI ❑ CORPORATION #r PARTNERSHIP❑# LLC❑# COMPANY NAME L`�4:� 1-4- 4 ,- ADDRESS s (,. I VC-r_ 4./4 CITY S- az?4 7 1) STATE /1( ZIP 0)6C o TEL FAX CELL-C°5- ye6 7- &---EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT n n FEE: $ PERMIT ft PLAN REVIEW NOTES