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Home My WebLink AboutBLDG-23-004263 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1,..1R)Rb CITY YARMOUTH J MA DATE February 01,2023 PERMIT# BLDG-23-004263 JOBSITE ADDRESS 17 THACHER SHORE RD OWNER'S NAME GEORGE THOMAS ANDREW TR G OWNER ADDRESS GEORGE QUALIFIED PERS RES--R 48 CYPRESS POINT YARMOUTH PORT MA TEL 02675 TYPE OR OCCUPANCY TYPE COMMERCIAL [1 RESIDENTIAL 111 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 1 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 ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKIN3 THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have :he 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 LESTER WADE LICENSE# 4569 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME LESTER J WADE ADDRESS. 22 CAPTAIN ISIAHS RD,22 CAPTAIN ISIAHS RD CITY COTUIT STATE MA ZIP 026352702 TEL FAX CELL EMAIL info a( ccipgenerators.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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS hi ING WORK CITY l r ww u4- 11 MA- DATE 1 a(-Y PERMIT# �- ! 1-LC° JOBSITE ADDRESS 1"I Z It a c. S k o Y'C. IC.4• OWNER'S NAME t A-S two✓7 L GOWNER ADDRESS %I CL. above. TEL.Co -3Goa-Vio FAx TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY .NEW:El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 2 APPLIANCES Z FLOORS-, BSM i 2 3 4 5 6 7 8 9 10 1 11 12 13 i4 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY-COCKS 1 MAKEUP AIR UNIT OVEN 1 POOL HEATER ROOM!SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER I _ 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 El NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY CR 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. 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 and accurate to the best of y knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in compliance ' all P i on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASH I!tit NAME Le5f"e-v` KM at- LICENSE# 4 5(o SI RE MP❑ MGF® JP❑ JGF❑ LPG❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Cap e_C cPTiftet4.peci d? 0.-¢ t?ot-c,-.r ADDRESS 43 Benc eAt Is II Ref CITY oket stA p- .e STATE MA _ ZIP L.(0 49 TEL 5O S-4l l g 1 FAX 00k'� CELL 5CK-I5O--TEI8 EMAIL ', 14.4)C.c= ej1e-4-c=+F>rS. cam•: ire