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HomeMy WebLinkAboutBLDG-23-002900 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,>G - CITY YARMOUTH MA DATE November 28,202:PERMIT# BLDG-23-002900 JOBSITE ADDRESS 108 STUDLEY RD OWNER'S NAME RODOALPH BRIAN W TR G OWNER ADDRESS DEL-REE REALTY TRUST 7 FIELD ISLAND POINT SANDWICH MA 02563-2769 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES 0 NO❑ FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 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 I 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 0 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 Dennis Gagne LICENSE# 9804 SIGNATURE MP©MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: DENNIS M GAGNE ADDRESS. 31 Cherrywood Ln, CITY Marstons Mills STATE MA ZIP 026481761 TEL FAX CELL EMAIL gagnedmg5tI0-aol.com 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 litir,M,A.,„le MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - 71 �,�� CITYAa (�' .^� v MA DATE 2 3 - 2- ---1- PERMIT '�3 Z 9 0� r ;% JOBSITE ADDRESS ) OS C-T-Ut +D 1 ) OWNER'S NAME tc^ ^ 06V c: t A/ GOWNER ADDRESS .l e l �.& . .'1T4 , r TEL F;yy, TYPE OR OCCUPANCY TYPE COMMERCIAL nEDUC ED UCATIONAL ❑ RESIDENTIAL �"PRTCLEARLY NEW: RENOVATION: ❑ REPLACEMENT: E'r PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES tt FLOORS--F 6S1v1 1 2 3 4 5 5 7 0 9 10 BOILER - l.I 12 13L1-___14 BOOSTER CONVERSION BURNER COOK STOVE DIRE CT VENT HEATER DRYER FIREPLACE FRYC)LATOR FURNACE ----� GENERATOR " ) ; GRILLE INFRARED HEATER LABORATORY COCKS —� --_ MAKEUP AIR UNIT } OVEN POOL HEATER ROOM ; SPACE HEATER ECEIVEDI ROOFTOP UNIT TEST ii'JV __ � � � i UNIT HEATER UNVENTED ROOM HEATER WATER Ft H SATE f� ruln N C; ;�;�FART�i F N T1 r_____HH OTHER Il INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IMIGL. Ch. 142 YES [CIO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ • OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 14.2 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. �e 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 and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinentprovision knowledge Massachusetts State Plumbing Code and Chapter 142 of the General Laws. of the `Z PLUMBER-GASFITTER NAME r { -' '� Crn-A LICENSE # Yk U • SIGNA .7 a� � MP i MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ 4i PARTNERSHIP ❑ # LLC COMPANY NAME 6-d.-G-A s_ ,'---1 )-1 ADDRESS 3 I �C\ n iiv CITY \ON7LA utk : ‘ ( , STATE MA-' ZIP a 7 6 TEL FAX CELL ' ) - 6- 6 ") a‘-( EMAIL L1,1 (t (Ls2. NOl -`\1_ att. iv. 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