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HomeMy WebLinkAboutBLDG-23-005535 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK c CITY YARMOUTH J MA DATE April 05,2023 PERMIT# BLDG-23-005535 JOBSITE ADDRESS 30 TOWN HALL AVE OWNER'S NAME FRENCH JOHN S G OWNER ADDRESS FRENCH JULIA T 30 TOWN HALL AVENUE SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES❑ NO El 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 _LABORATORYCOCKS - - 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 El 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 Douglas Langtry LICENSE# 11305 SIGNATURE MP El MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: AQUA SERVICES ADDRESS. 1200 Route 28,1268 ROUTE 28 CITY 'South Yarmouth STATE MA ZIP 02664 TEL 5086193367 FAX ' 'CELL EMAIL douo-aquaWcomcastnet 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 FITTING WORK YARMOUTH 4/5/2023 !1(� Z�j~- S `j CITY MA DATE RM�# JOBSITE ADDRESS 30 TOWN HALL AVENUE FRENCH OWNER'S NAME GOWNER ADDRESS SAME TEL 508-364-8438 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ■ PRINT CLEARLY NEW: U RENOVATION: n REPLACEMENT: • PLANS SUBMITTED: YES NO ■ APPLIANCES Z 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 HEATERrREcEROOM / SPACE HEATER ROOF TOP UNIT r TEST PR 05 202.3 T HE ATER EATER UNVENTED ROOM HEATER RUVLiDING uG1-Kf-_i"NtiEN7 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 n NO 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 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 t. e best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in eso ce with all P-. inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME DOUG LANGTRY LICENSE # 11305 OriTURE MP ■ MGF JP JGF LPG' CORPORATION n # PARTNERSHIP n # LLC ■ # 3081 COMPANY NAME AQUA SERVICES PLUMBING & HEATING ADDRESS 1200 ROUTE 28 CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-619-3367 FAX 508-619-3367 CELL EMAIL DOUG-AQUA@COMCAST.NET 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 4