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HomeMy WebLinkAboutBLDG-22-005999 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK q� •' 1a CITY YARMOUTH MA DATE April 19,2022 PERMIT# BLDG-22-005999 JOBSITE ADDRESS 21 TELEVISION LN OWNER'S NAME STANDRING HAROLD J(LIFE EST) G OWNER ADDRESS 21 TELEVISION LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El 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 1 DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR FURNACE 1 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 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 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 Richard Ahern LICENSE# 11340 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RICHARD C AHERN ADDRESS. 67 Hayward Dr, CITY Stoughton STATE MA ZIP 020723811 TEL FAX CELL EMAIL rich a(�corvoproperties.com 1 S31ON M3IA321 NVId #1I1A1213d $:33d ❑ ❑ 1111213d 3H1 SY SAS NOIlvOIlddV SIHl ON SOA S3 LON NO1103dSNI 1VNId AINO 3Sf1 210103dSNI 2JOd 30Vd SIHL S310N NOI103dSN1 SVO HOl021 g-6 .oD i E B4SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY AY.7.:tc,iQGC/A�. MA DATE -Y//9 2 2. PERMIT# '-1— S-9 51 9 022 JOBSIrE,,,DDRESS 21 7`1vrs/D4.4 1....,�f OWNER'S NAME r.UILD EP RI11���� C� / / 'f�—�� 1 e,. owN�f ADDRESS '1 /CLAP f s, (l_Au/z,Lel C.14 TE,47(�1 �j5 F„X ! TYPE OR t < �� PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL IDRESIDENTIAL Ir.-- CLEARLY NEW:❑ RENOVATION: Er REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO 0 APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 BOILER 9 10 11 12 13 La BOOSTER CONVERSION BURNER COOK STOVE / DIRECT VENT HEATER DRYER - !— FIREPLACE I FRYOLATORf FURNACE ' —7--- -- — GENERATOR --`— GRILLE '�— INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN - f---- POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT TEST ----- UNIT HEATER -----_ UNVENTED ROOM HEATER WATER HEATER __ OTHER —�-- _ • 1 INSURANCE COVERAGE I have a current lia bili insurance policy or its substantial equivalent which meets the requirements of MGL_Ch.142 YES Np I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE , Y CHECKING THE APPROPRIATE BOX BELOW ❑ LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does riot 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 CHECK ONE ONLY: OWNER ❑ AGENT El I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ccurate to the best of my knowledge `— and that all plumbing work and installations performed under the permit issued for this application will be in cpfnplian with all P rtinent provision of the�` PlumbingChapter142 of the General Laws. Massachusetts State Code and '�1 , � PLUMBER ,ASFITTER NAME (` L LICENSE#t//P ' SIGNATURE MPj GF❑ JP ❑ JGF 0 LPG! ❑ CORPORATION❑# PARTNERSHIP❑# LLC l�tt 06— COMPANY NAME /1/Airn �`. 7/ //4 ADDRESS 4/ ?Of 4< `_""' CITY y/7L�,V STATE/4 ZIP 2 ZG ?z TEL G FAX CELL �f c't EMAIL i/ --‘) J• GIB GASSPEd� ' C�I'� IfS THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES S ROLJ Yes No THIS APPLICATION SERVES AS THE PERMIT fl FEE: $ PERMIT # PLAN REVIEW NOTES 9