HomeMy WebLinkAboutBLDG-22-007463 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Vidf CITY 'YARMOUTH I MA DATE June 28,2022 PERMIT# BLDG-22-007463
JOBSITE ADDRESS 45 PRINCE RD OWNER'S NAME ZORZI FAMILY LLC
G OWNER ADDRESS 45 PRINCE RD WEST YARMOUTH MA 02673 1 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT.❑ PLANS SUBMITTED:YES 0 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
GRILLE
INFRARED HEATER
LABORATORY COCKS _
MAKEUP AIR UNIT
OVEN
POOL HEATER •
_
ROOM/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 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LABILITY INSURANCE POLICY 0 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 as 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 Patrick Dempsey LICENSE# 15176 SIGNATURE
MP 0 MGF 0 JP 0 JGF❑ LPG! 0 CORPORATION 0# PARTNERSHIP ❑# LLC❑#
COMPANY NAME: PATRICK J DEMPSEY ADDRESS. 26 LYME ST,
CITY EAST WEYMOUTH STATE MA ZIP 021891023 TEL
FAX CELL EMAIL none
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li� t>atl}SSACHUSETTSZUNNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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PRINT • = LY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ra" PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES T FLOORS-I BSM 1 ' 2 3 4 5 6 7 8 9 11 'I9 12 13 I 14
BOER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER �____
FIREPLACE i
FRYOLATOR
FURNACE
GENERATOR
GRILLE i
INFRARED HEATER
LABORATORY COCKS ----i
MAKEUP AIR UNIT • —
OVEN
POOL HEATER L_____�
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST7—±--
UNIT HEATER . _..._.._ .._ :• ---
INVENTED ROOM HEATER •
WATER HEATER
OTHER
l ,i2f2p6-c-eill 2 AIL/7 Ditcvq1.4-
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 COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Err OTHER TYPE INDEMNITY IDBOND ❑ 1
• 1
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 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 pli nce with II inert provision of the
Nr` Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE f*
S/ ze, �. ,../../ SIGMA URE
MP Of MGF❑ JP [7JGF ❑ LPGI ❑ CORPORATION❑# PA. TNERSHIP # C
COMPANY NAME1/2---- r.4S+ 6 �
ADDRESS ( /7.A,P V
CITY STATE 9r ZIP G 4/ Q TEL c-L10 -4117— zlcs, 36-/'
FAX CELL7J/' 7/c- G'�‘ 7 EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes N
THIS APPLICATION SERVES AS THE PERMIT I
FEE: PERMIT ff
PLAN REVIEW NOTES