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HomeMy WebLinkAboutBLDG-22-006801 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK W CITY YARMOUTH MA DATE (May 24,2022 I PERMIT# BLDG-22-006801 JOBSITE ADDRESS 534 WINSLOW GRAY RD OWNERS NAME YARMOUTH HOUSING AUTHORITY G OWNER ADDRESS 1146 ROUTE 28 SOUTH YARMOUTH MA 02664-4463 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ 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 1 GRILLE INFRARED HEATER LABORATORY COCKS 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 ❑ NO 0 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 (Jamie Labonte I LICENSE# 15716 SIGNATURE MP©MGF❑JP❑ JGF 0 LPG( ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: JAMIE R LABONTE ADDRESS. 1316 ROBERT ST, CITY WESTPORT STATE MA ZIP 027904920 TEL I FAX CELL EMAIL (none S310N M3IA3a NV1d #iIWH3d $ :33d ❑ II112f3d 3H1 SV S3A2i3S NOIlVDIlddb SIHI ON SeA S310N NOI103dSNl lYNId AINO 3Sf1 a0103dSNI HOd 39Vd SIHl S3lON NO103dSNI SVO HJfOa ,'` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r gf `Y e,' CITY -` ‘ "1 i 7 �" PERMIT* Z Z _C40 JOBSITE ADDRESS 57). l'A k..4\gv•,IVwuve\A 1\C) OWNER'S. NAME ` t`-‘t' '''-1" ( kAH1/11, l'atI i GOWNER ADDRESS TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL❑ CLEARLY NEW:0 RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ I,IO❑ APPLIANCES . FLOORS-4 BSM 1 2 3 1 5 6 7 0 9 10 '11 12 BOILER '13 1' BOOSTER �� CONVERSION BURNER - ___________,I COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GRILLEGENERATOR, c3 ,�� 1 _I i INFRARED HEATER —� -,-� LABORATORY COCKS i MAKEUP AIR UNIT OVEN I POOL HEATER • 1 ROOM!SPACE HEATER ROOF TOP UNIT ___ TEST • _ UNIT HEATER UNVENTED ROOM HEATER • 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 g] NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW L{ABILITY INSURANCE POLICY © 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• I hereby certify that all of the details and information I have submitted or entered regarding this application are tr e 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 comp ce with all Pertinent provision of the4 J Massachusetts State Plumbing Code and Chap ter 142 of the P General Laws. PLUIt4BER GASFITTER NAME °""C � . �- LICENSE# 1 rj1l AA SIGNATURE MP g MGF ❑ JP ❑ JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# LLC COMPANY NAME >' Z ; PAV ,': \ b ADDRESSSc ❑#: Cl u5\',x,\\r- STATE; ZIP ' ----)1(� TEL C( "a(. ) " L(f13 FAX CELL EMAIL ThiSP'EC--L — NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Ye5 No THIS APPLICATION SERVES AS THE PERMIT 1 FEE: $ PERMIT # PLAN REVIEW NOTES a