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HomeMy WebLinkAboutBLDG-22-005609 LL-:., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 'April 04,2022 I PERMIT# BLDG-22-005609 JOBSITE ADDRESS 1.908&928 ROUTE 28 OWNERS NAME (BASS RIVER REALTY LLC I G OWNER ADDRESS 113 PLEASANT ST SOUTH YARMOUTH MA 02664 TEL I _ I TYPE OR OCCUPANCY TYPE COMMERCIAL J❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ 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 2 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY❑ 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 Dean Farnham LICENSE# 13203 SIGNATURE MP©MGF❑JP 0 JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: DEAN P FARNHAM ADDRESS. 8 WILLOW WAY, CITY SOUTH DENNIS STATE MA ZIP 026603060 TEL _ FAX CELL EMAIL deanfamham560amail.com S310N M31A32i NYld #1IW2N3d $ :33d ❑ ❑ 1R 2d 3H1 SV S3A213S NOI1VO lddV SIHl oN se), S31ON N01103dSNI 1VNId AlNO 3Sl 2J0103dSNI 2i0d 39Vd SIHI S31ON NO1103dSNI SVJ HOf102! ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK le-Mc ,4ts CITY- �C,,�"�? IJ�, DATE l -� PERMIT ZZ- 5 6 0 2-2 5 JOBSITE ADDRESS i 1 2 0 C OWNERS NAME ,'" 43 ,rl�i� G OWNER ADDRESS TEL�� �i' TYPE OR FAX PRINTOCCUPANCY TYFE COMMERCIAL EDUCA T ION.4L ❑ RESIDENTIAL ❑ CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-4 8 M 1 BOILER 2 3 4 5 fi ? g 9 10 11 12 13 L 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER —`— DRYER FIREPLACE FRYCiLATOR 1 FURNACE ---- GENERATOR GRILLE • �_--- INFRARED HEATER i LABOP.ATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER • C D -1----- ROOM/SPACE HEATER ROOF TOP UNIT _ TEST - g :21.12Z - UNIT HEATER UNVENTED ROOM HEATER _ iNATER HEATER i3hPJC F C#EN7 T OTHER T I. INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES W6 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG 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 requirennent. SIGNATURE OF OWNER OR AGENTCHECK ONE ONLY: 0 NER ❑ AGENT ❑ I hereby certify that all of the details and information I have submitted or entered regarding this application are true - `- and that all plumbing work and installations performed under the permit issued for this application will be in compl':nce with all o Li�' Massachusetts State Plumbing Code and Chapter 142 of the Generalof my knowledge 1 Pt Laws. i _provision ate �e • PLUI�A6E GASFITTER NAME A �__ LICENSE## ��70 ' , `NATURE MP MGF❑ JP ❑ JGF❑ LPG' ❑ CORPORATION❑## PARTNERSHIP❑## LLC # COMPANY N EDec_i .- G G - ' ADDRESS (L./r Ifs c_,/G CITY S• r' r S STATED_ ZIP 6 6 G TEL 1-/6 - ' FAX CELL EMAIL S.? C.-K4 j 0 C n c., J. C 41 t -t ='7s ICROUGH I 3' 'ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES `(ez N�THIS APPLICATION SERVES AS THE PERMIT l FEE: $ PERMIT PLAN REVIEW NOTES