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HomeMy WebLinkAboutBLDG-22-001162 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE August31,2021 PERMIT# BLDG-22-001162 JOBSITE ADDRESS 15 BURCH RD OWNERS NAME FERULLO GLORIA R TR G OWNER ADDRESS 26161 SUMMER GREENS DR BONITA SPRINGS FL 34135 TEL L TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO 0 FIXTURES FLOORS—r BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY 0 BOND ❑ OWNERS 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 David Houde LICENSE# 16673 SIGNATURE MP©MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0#1 COMPANY NAME: ADDRESS. 1016 Queen anne rd, CITY Harwich STATE 1-7 ZIP 02645 TEL FAX CELL EMAIL davidhoude6(dpmail.com • S310N M31/132:1 NVlld #±IV I d $:33d ❑ 0 1I141213d 3H1 SV S3A2J3S NOIlV3Ilddd SIHI oN saA S310N N01103dSNI 1VNI3 NINO 3Sl 2J0103dSNI 2103 39Vd SIH1 S310N NO1103dSNI SVO HOflO MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CI I CITY Q'y/� ��' j Imo, DATE PERMIT# Z2 - I(t..Z 111 '1 '✓ N E JOBSITE ADDRESS / OWNER'S NAME PP d"C-11 D CY'D' OWNER ADDRESS TEL FAX 0 EYPE R OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL®-- f CLEA NEW:❑ RENOVATION: V REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ T 77P LIANCtti-4 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 1 BOILER BOOSTER CONVERSION BURNER. _ COOK STOVE I -� DIRECT VENT HEATER DRYER FIREPLACE I 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 I 1 H INSURANCE COVERAGE 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 COVE 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 an 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 corn Ii c with all Pertinent pro on of the • Massachusetts State Plumbing Code and Chapter 142 of the Gene al Laws. PLUMBER-GASFITTER NAME 0 a vt G 7 0 v' LICENSE# �� v U 7 I SIGNATURE Lam MP ' PJIGF❑ JP [] JGF LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# ?7 4 COMPAN 'I ME Pi- /1 / /�l ADDRESS / U/ � �( e a, ,/�<7!� �� CITY five C/ STATE/MI ZIP C46�l TEL L` q FAX CELL EMAIL 1.0 G (Gt L 4 6 CT-*,/ 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 • • • • •