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Home My WebLink AboutBLDG-21-007333 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i CITY LARMOUTH MA DATE June 16,2021 PERMIT# BLDG-21-007333 JOBSITE ADDRESS 10 BREEZY POINT RD OWNER'S NAME todd pare G OWNER ADDRESS 10 BREEZY POINT RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ 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 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 ❑ 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 Jared Wilber LICENSE# 15219 SIGNATURE MP Q MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# ] COMPANY NAME: JARED WILBER ADDRESS. 474 WINSLOW GRAY RD, J CITY S YARMOUTH STATE MA ZIP 026644317 TEL ] FAX CELL EMAIL I L 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 --=— r ASSACHUSETTS UNIFORIVI APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I �.7s t _s -'t*. , CITY 1iQ,Y' Er) OR 1-1 1 MA DATE 6 / S —1.j PERMIT*Q( b6 -7k oo 33 3 ; `= - JOBSITE ADDRESS II d 3 re "Y.tv ec•.x-'E g d OWNERS NAME r Y`ra Lint - _ OWNER ADDRESS 5 Gi C TEL FAX R , I'�tDI OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL[ +-CLE'Llt—L , (_ NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ '41/4• PPLI.ANCES T FLOORS 6S1u1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 r; T;EOI_ER BOOSTER CONVERSION BURNER COOK STOVE -; DJR&tCT VENT HEATER DRYER �-...--FIREPLACE •- --- FRYCiLATOR FURNACE GENERATOR GRILLE I i INFRARED HEATER . LABORATORY COCKS MAKEUP AIR UNIT J OVEN POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER _ _ 1 l INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES E hl �,/ 0 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ikri 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 CMassachusetts General Laws,and that my signature on this permit application waives this requirement. I. J CHECK ONE ONLY: OWNER ❑ 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 4`- and that all plumbing work and installations performed under the permit issued for this application will be in compli ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. & PLUIV1BER-GASFITTER NAME LICENSE 4 j.7,Z j? SIGNATURE MP I MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION " fi PARTNERSHIP❑4 LLr ❑ /I J COMPANY NAME '(c(P . S ?iUWZl1' Itl ADDRESS V 79 Vi IIS'�.) �� (41. i CITY yo- im b 1A 5 ATE MA_ ZIP Q�. TEL q TEL FAX CELL D dd 5!71 Oo V EMAIL r1 c(-Y_ ,. -f hl C J , Unci;L CO�'1i, THIS PAGE FOR INSPECTOR USE ONLY' FINAL INSPECTION NOTES Ye5 NQ THIS APPLICATION SERVES AS THE PERMIT (� FEE: $ PERMIT # PLAN REVIEW NOTES