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HomeMy WebLinkAboutBLDG-22-006996 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ViI q' CITY YARMOUTH MA DATE June 03,2022 PERMIT# BLDG-22-006996 JOBSITE ADDRESS 1 LEGEND DR OWNER'S NAME SULLIVAN BRIAN S G OWNER ADDRESS SULLIVAN JILL M 1 LEGEND DR SOUTH YARMOUTH MA 02664 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0 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 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 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 CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF 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. 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 Zachary Lucas LICENSE It 16865 SIGNATURE MP©MGF❑JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: MID CAPE MECHANICAL ADDRESS. 300 Queeen Anne Rd., CITY Harwich STATE MA ZIP 02645 TEL FAX CELL EMAIL midcapemechanicalpWgmail.com S310N M3IARI Ndld #iJI 3d $:333 ❑ ❑ 11112:13d 3H1 SV S3AN3S NOIlVOIldd`d SIH1 ON seA S310N NOI103dSNI 1VNI NINO 3Sf1 I0103dSNI d03 3OVd SIH1 S310N N01103dSNI WO HOflOd reaQ rti _ ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,fs,,., ZIYY QrMOokhhr2gQ1 �Mu,r DATE OG 02/ZZ PERMIT# 22- (o`�91m Min- RESS I(^ l OWNER'S NAME BUIL G DE RESS / U Pn'oe TEL3IO 1� 7FAX a'T YP'E-6R PRINT "OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL®— CLEARLY NEW:ID RENOVATION:❑ REPLACEMENT:ByPLANS SUBMITTED:YES❑ NO 0 1 i APPLIANCES 1 FLOORS- BSM 1 2 3 a 5 6 9 10 11 12 13 I 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER ! DRYER - FIREPLACE ! FRYOLATOR - FURNACE GENERATOR I — GRILLE INFRARED HEATER - LABORATORY COCKS • - —{ MAKEUP AIR UNIT I OVEN ' POOL HEATER - - ROOM I SPACE HEATER ROOF TOP UNIT TEST _. • • • ..._ -_.. JI UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I I 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 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY 0 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. CHECK ONE ONLY: OWNER❑ AGENT 0 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 II Pertin t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. W. PLUMBER-GASFITTER NAME 711r La ar 1.0 c4-5 LICENSE# (6 865 S GNATURE MP Er MGF 0 JP 0 JGF 0 LPGI❑ CORPORATION❑# PO ❑# LLC 0# COMPANY NAME M�� C40" �IQG ius r.i Ca PO 1 ADDRESS (aC.) - hl 3 CITY b.-)< CL ot'ilka.w STATE NR 4 ZIP 02.69 C R TEL 508 Z 9'G ?2)7 FAX CELL EMAIL W1 i ,2d4,11kka l iDOWAct,I,C.", 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_