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Home My WebLink AboutBLDG-22-005575 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK W' CITY YARMOUTH MA DATE 'April 01,2022 I PERMIT# BLDG-22-005575 'v JOBSITE ADDRESS 9 AMELIA WAY OWNER'S NAME STEVEN SYLVIA G OWNER ADDRESS 9 AMELIA WAY SOUTH YARMOUTH MA 02664 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q 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 1 •_ _ 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 El 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 (Gregory Daubed. I LICENSE# 125657 I SIGNATURE MP❑MGF❑JP 0 JGF Cl LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME: GREGORY A DAUBERT ADDRESS. PO BOX 615. CITY S YARMOUTH STATE MA ZIP 026640615 TEL FAX CELL EMAIL S310N M3IA321 NVld #JI1/1213d $ :333 ❑ ❑ II11a3d 3H1 SV S3AH3S N011v011ddv SIHI oN seA S310N N01103dSNI lYNl3 AlNO 3Sf1 10103dSNI 210d 3OVd SIHI S31ON NOI103dSNI SVO HOf102' R Ø. DA SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM FITTING WORK ;•,- ;AV.'S- ,CIT' , / - 1 A--1 OM �� ,,, MP' SATE Z _PPERMIT �- i -z 3 JGBaITE ADDRESS 7 f►') j �;�iG , _I�1cR - a ILDI EPA TMENT OWNER'S NAME _ y,+� OWNER ADDRESS' By _ �. /� ' .s. ,1.,_k • TEL V��9) 8 1 5-- C� TYPE OR ________________ PRINT OCCUPANCY TYPE COMMERCIAL 1-1EDUCATIONAL I-1 RESIDENTIALO CLEARLY NEW: 64 RENOVATION: ❑ REPLACEIv1EW: PLANS SUBMITTED: YES NO ❑ APPLIANCES -1 FLOORS--+ 6`Ivl 1 _? 3 4 BOILER 57 8 9 10 I I'I 12 13 1! BOOSTER CONVERSION BURNER fCOOK STOVE , DIRECT VENT HEATER DRYER - _--, FIREPLACE FRYOLATOR FURNACE GENERATOR X ! GRILLE i`-- INFRARED HEATER �- ____ --� LABORATORY COCKS —� MAKEUP AIR UNIT . 1 OVEN _ POOL HEATER - ROOM I SPACE HEATER ROOF TOP UNIT - • , TEST , UNIT HEATER - f UNVENTED ROOM HEATER . WATER H E'�TE R OTHER INSURANCE COVERAGEI have a current IiabiBi insnrance policypolicyor 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 ❑ OTHER TYPE WiIDEMNITY n BOND • n D> iNIER,s INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required Chapter 142 Massac .ef:te General La . ind that my signature on this permit application waives this requirement, by of the r CHECK ONE ONLY: OWNER 1'/1 AGENT SI �N,13,TURE OF OWNER ORLAG n '71, �EI�T � 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 and that all plumbing work and installations performed under the permit issued for this application will be in compliance with of provision knowledge th Massachusetts State Plumbing Code and Chapter .I42 of the General Laws. P all Pertinent oftl�e '�1 - PLUMBER-GASFITTER NAME LICENSE #aRp,5 ' ,..7 A214eA, a (:Z_,ex_S----- SIGNATURE MP ❑ MGF ❑ JP y JGF n LPGI n CORPORATION ❑ f: PARTNERSHIP E. # COMPANY NAME 6 Z i G S \o\ Y.) i ADDRESS /616) r iL( 7.. CITY Yflfl/ o a T 11 Port r 1 nn � -� STATE 1V)0 r'"�._ ZIP Od 6 /,S TEL 71 Y -02.0C - 9(j FAX CELL 77Y -A / '- U '90 EMAIL Giz 6 Alio 6 rfe1 P_ 6 M i)k A CO Adr) ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT# PLAN REVIEW NOTES • •