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HomeMy WebLinkAboutBLDG-22-002683 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e=ffit CITY YARMOUTH MA DATE November 09,202" PERMIT# BLDG-22-002683 ti JOBSITE ADDRESS 573 ROUTE 28 OWNER'S NAME THE MARINER MOTOR LODGE LLC G OWNER ADDRESS 573 ROUTE 28 WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ 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 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:room heater 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 0 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 Peter Riva LICENSE# 13447 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: PETER E RIVA ADDRESS, 9 BAYVIEW ST, CITY MARSHFIELD STATE MA ZIP 020502906 TEL FAX CELL EMAIL peterriva(aicomcast.net S310N M31A3ZI NV-Id #111Na3d $:33d ❑ ❑ 1IV 3d 3E11 SV S3Ai13S NOI1VOIlddV SI1-11 ON SO), S310N N01103dSNI IVNId AINO 3Sl 80103dSNI 210d 39Vd SIHl S310N N01103dSNI SVO H9f102i �=� ,- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK liMEIK:_t6 CITY VI\ (r4 t v \ - Cs * MA DATE \ Z � PERMIT JOBSITE ADDRESS 573 �� -' �. irl'° OWNER'S NAME 4". OWNER ADDRESS TEL OK 727-7 FAX mkPt'Pc ?t'PRINT OR • OCCUPANCY TYPE COMMERCIAlirT EDUCATIONAL RESIDENTIAL 'r.r�l�l^ CLEARLY NEW: ❑ RENOVATION REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES -1 FLOORS--4 BSIO 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BOILER BOOSTER —� CONVERSION BURNER —� COOK STOVE DIRECT VENT HEATER DRYER, FIREPLACE I I FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN i POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER • _.... (INVENTED ROOM HEATER WATER HEATER I OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES -❑ NO ij I IF YOU CHECKED YES, PLEASE INDICATE THETYPE r OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ I OWNER'S INSURAI'4OE 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 n AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true 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 co is with all rtinent provision of the Massachusetts State Plumbing Code - chapter -14 General Laws. /e ,�- PLUMBER-GASFITTER NAME `�/ 1 t/ LICENSE# � zin SIGNAT ,E MP2 MGF ❑ JP ❑ JGF ❑ LPGI El CORPORATION ❑ # PARTNERSHIP ❑ # LLC E•#: C2-3`i` COMPANY NAME (V,'���1 /1 `C "57 6/1 ._- / - ADDRESS 11-C CITY , l 6Z -6 O 6 . STATE (/v � ZIP S TEL � �� Z �f FAX _5-Zi4.471 C CELL %I 2L ,S IL1 EMAIL / Cbvc L. 44 l 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 • •