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HomeMy WebLinkAboutBLDG-22-001002 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "` CITY 'YARMOUTH I MA DATE 'August 23,2021 I PERMIT# BLDG-22-001002 JOBSITE ADDRESS 143 WEBSTER RD I OWNER'S NAME 43 Webster Rd LLC G OWNER ADDRESS TELI 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 1 _ DIRECT VENT HEATER DRYER FIREPLACE 1 _ FRYOLATOR FURNACE 1 1 • 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 1 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 nol 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 Robert Maizaka LICENSE# 10659 SIGNATURE MP©MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: ROBERT W MAIZAKA ADDRESS. 3 CIRCLE CLOSE,PO BOX 1092 CITY ORLEANS STATE IMA I ZIP 1026531092 _I TEL FAX CELL 7748365585 EMAIL bobmaizakana,comcasLnet 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 4\CI) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: /i M&V 41 MA. DATE i-cAt5. 210, i PERMIT# Z JOBSITE ADDRESS 3 it)147S A AC) OWNER'S Nam /�/iFrS �c.z3 GOWNER ADDRESS: TEL: FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL gr PRINT CLEARLY NEW:Wr RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0 APPLIANCESZ FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ BOOSTER CONVERSION BURNER _ COOK STOVE 3- DIRECT VENT HEATER DRYER FIREPLACE 1 _ FRYOLATOR FURNACE .1 _ GENERATOR GRILLE VI INFRARED HEATER _ LABORATORY COCK MAKEUP AIR UNIT ' OVEN POOL HEATER ROOM/SPACE HEATER J ROOF TOP UNIT fi TEST 1 UNIT HEATER 14.1 UNVENTED ROOM HEATER WATER 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 have 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 ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the of my Knowledge and that all plumbing work and it istallations performed under the permit issued for this application WN with Perthent provision of the Massachusetts State " Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITT NAME: 1 CJ 1(J /14 2,94- LICENSE# I015;59 SIGMA COMPANY NAME: c' eA tA-/- ADDRESS: Pam' x 1d9a CITY: CaLQ,VsS STATE:./t(ct. ZIP: C€S3 FAX TEL: 77'1 --'5\35-SSLS CELL EMAIL: /11/1 e?a.1`..Ue r MASTER +Q.—JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# I,r c h7/3i[, ADD2&SS: _ J1 /6_ @ '4t/c/,T-1-.-.(4,i