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HomeMy WebLinkAboutBLDG-23-005787 0^ "" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTHk,,, ' MA DATE April 19,2023 PERMIT# BLDG-23-005787 JOBSITE ADDRESS iliti)&184 Minallir '-:*L T� —I 0 NER'S NAME B ffa) COALS G OWNER ADDRESS BRIG' MANDALAY RD LEE MA 02138 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ 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 1 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 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 ❑ NO❑ 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 Kesuqs Lopez LICENSE# 16301 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: KESUQS LOPEZ ADDRESS. 107 Meetinghouse Rd, CITY Mashpee STATE MA ZIP 026492617 TEL FAX I I CELL I (EMAIL klopez2k11(@.qmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El 0 FEE:$ PERMIT# PLAN REVIEW NOTES w -•-• -/' ' �'` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK p ,=l_ .� t. ,_ CITY VO'IcYY7C)040 _ Mr, DATE II IIii1 � PERMIT#. � ; JOBSITE ADDRESS i q Sep L'P`��U Avet'` -3t OWNER'S NAME FiCa4-il iev- tva,r GOWNER.ADDRESS ! ,Y1/1 5eci VlCw Aix TEL(77v);33-/1 O FAX t l TYPE OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRIN ❑ ❑ RESIDENTIAL[� CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NOT APPLIANCES 1 FLOORS-+ BSIvl 1 2 3 4 5 6 7 ll 9 10 11 12 13 14 BOILER 4_ BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYC)LATOR 1 ' FURNACE GENERATOR. GRILLE i INFRARED HEATER r-- -1 LABORATORY COCKS MAKEUP AIR UNIT fI -•----, OVEN 1 E t E IV-F.: D - POOL HEATER ROOM;SPACE HEATER a C 2� ROOF TOP UNIT Tr [-I ilr TEST _...- UI�lIT HEATER L�Uil i ___ r) ' x,r-� t_ UNVENTED ROOM HEATER • �- WATER HEATER OTHER L—_ INSURANCE COVERAGE 4 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 THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I ant 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 my knowledge `k- and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi all Pertinent of the `' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Q1 I PLUMBER-GASFITTER NAME / 1Sv /.e% Z LICENSE# A 30/ SIGNATURE MP 511 MGF❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑11 PARTNERSHIP �❑Q 1i LLC❑i COMPANY NAME ..LA)Ct1 lot, ?�L.)-ibi ADDRESS /O7 J kcT ' f ] `'ib(ASe lq CITY l r IQ � STATE PIA 1 ZIP C 1 C/TEL(77y)23``�U / C FAX CELL ` 7 ll)28-)660 EMAIL Xt e-,FC2 agGy 1 / C OM IDS 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 • • • • • 1