HomeMy WebLinkAboutBLDG-22-006672 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE May 18,2022 PERMIT# BLDG-22-006672
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JOBSITE ADDRESS 62 GREAT WESTERN RD OWNERS NAME Margaret Keras
G OWNER ADDRESS 102673 TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL 0
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO❑
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 1
FIREPLACE 1
FRYOLATOR
FURNACE 1
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 1
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 0
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 [Michael Saurette LICENSE# 34174 SIGNATURE
MP❑MGF❑JP 0 JGF❑ LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑#
COMPANY NAME SAURETTE BROTHERS ADDRESS. 7 Barnhouse Road,7 Barnhouse Road
CITY Dennisport STATE Ma. ZIP 02639 TEL
FAX CELL EMAIL rsox5555agmail.com
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[� SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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PRINT OCCUP.ANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIA4
CLEARLY NEW:pY RENOVATION: ❑ REPLACEMENT: ❑
PLANS SUBMITTED: YES ❑ i
APPLIANCES a FLOORS—F sSlul 1 2 3 4 5 6 7 o
BOILER y 10 l I 12 13 _I
BOOSTER
CONVERSION BURNER1 COOK STOVE
DIRECT VENT HEATER '
DRYER X )
FIREPLACE X
FRYOLATOR 1 I
FURNACE X
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 ' X
OTHER
1
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 TI-IE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
1
• OWNER'S INSURANCE WAIVER: I am aware that the icensee 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 ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
`i-• 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.
41
PLUMBER-GASFITTER NAME LICENSE#7(70 7 SIGNATURE
MP E MGF❑ JP JGF� (❑ LPG' ❑ CORPORATION❑1F PARTNERSHIP❑# LLC ElCOMPANY NAME v r�e-�-te DrU ADDRESS ! Da1rk ki rc+
CITY Denr►k5 pia- STATE /Yl.A ZIP Gab 3q TEL 7 744-S7O
FAX CELL EMAIL k saxcS509014i :CCOI
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