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HomeMy WebLinkAboutBLDG-22-007461 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 'June 28,2022 I PERMIT# BLDG-22-007461 JOBSITE ADDRESS 12 LYMAN LN OWNERS NAME IKILLINGER JUDITH A(LIFE EST) G OWNER ADDRESS 12 LYMAN LANE SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 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 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 El 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 wA be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 'John Kane I LICENSE# 22755 SIGNATURE MP❑MGF 0 JP© JGF❑ LPGI El CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: IJOHN KANE I ADDRESS. 139 MONOMOY RD, CITY IS YARMOUTH I STATE MA ZIP 026641984 TEL I FAX I I CELL I I EMAIL Iikanee45(dvahoo.com S310N M2IA32I Ndld #1IV d $ :33d ❑ ❑ 11W213d 3HI SV S3AHRS NOIIVDIlddV SIHI oN seA S310N NOI103dSNI 1VNId AlNO 3Sfl i0103dSNI 2i0d 3OVd SIHl S31ON NOI103dSNI SVD HOflO V '.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _ NI CITY 5 - -./0 v 0,14 e i" MA DATE A a A\?--- - PERMIT # ZZ — 7 k e/ JOBSITE ADDRESS 1 a- I-Y An 0 h 1 V1 OWNER'S NAME ndy ) ( l l ✓1 t OWNER ADDRESS 5 a vv\t TEL FAX r t OR TYPE �, uCCURANGY TYPE COMMERCIAL [1] EDUCATIONAL ❑ RESIDENTIAL ?[" CLEARLY NEW: ❑ RENOVATION: j] REPLACEMENT: 4 PLANS SUBMITTED: YES ❑ NO APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 9 10 'I1 12 13 1'. BOILER BOOSTER CONVERSION BURNER, _ COOK STOVE DIRECT VENT HEATER DRYER I _ FIREPLACE �� � I FRYOLATOR ^� FURNACE GENERATOR , GRILLE INFRARED HEATER LABORATORY COCKS i I. MAKEUP AIR UNIT I OVEN - i POOL HEATER , —� • i RECEIVED--.. --..— _.....„..7 ,' ROOM ; SPACE HEATER �.-~-- ROOF TOP UNIT II 2421:119 TEST .. . ___ { UNIT HEATER LINVENTED ROOM HEATER I El e JlI nlryr_ DE anRT MT i WATER HEATER —I.1� OTHER I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ® NO 1.1 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [A 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 requirement. I CHECK ONE ONLY: OWNER Q AGENT ❑ SIGNATURE OF OWNER OR AGENT %.1:- 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 Z Massachusetts State Plumbing Code and Chapter '142 of the General Laws. )4,...,/(k._, PLUMBER-GASFITTER NAME LICENSE # -al6-s- SIGNATURE MP ❑ MGF El JP 0 JGF ❑ LPG' ❑ CORPORATION ❑ li PARTNERSHIP ❑ # LLC ❑ # , COMPANY NAME .J 4 ck j,<:Q+brvc t .,(:$,n A. Cat "- k v)) ADDRESS 3 °I alO Vl a vx d y "a of. CITY S - y a r ran 0 01 STATE YY1 u ZIP O 'l i G 4 TEL FAX CELL 5-65( - Co?(S --;S b5 EMAIL .3 i6)► nc- (4-5 Q y4 V16 5 CO N-- c(67i: C 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