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HomeMy WebLinkAboutBLDG-21-006605 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `e' c CITY YARMOUTH MA DATE May 14,2021 PERMIT# BLDG-21-006605 JOBSITE ADDRESS 40 HATCH RD OWNERS NAME IPROVENCHER FREDERICKJ III 7 G OWNER ADDRESS PROVENCHER LYNN S 40 HATCH RD SOUTH YARMOUTH MA 02664-1937 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 12 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑ FIXTURES FLOORS—s 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 1 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 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 GregorySelfe LICENSE# 26714 SIGNATURE MP❑MGF 0 JP© JGF❑ LPG!❑ CORPORATION 0# J PARTNERSHIP 0# LLC❑# COMPANY NAME: GREGORY A SELFE ADDRESS. 141 SPRINGER LN, CITY WEST YARMOUTH STATE MA ZIP 026734930 TEL I FAX CELL EMAIL 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _'7"= o) s-13�a1 L0I ,. Z 1-6' c or _kz _;1 = CITY yr4tQAr► MA DATE PERMIT# _ JOBSITE ADDRESS 7 HAT CAI R Q MI OWNER'S NAME rn *e I) ?R o ven fie, GOWNER ADDRESS y O �� 1e o A_D TE( 3'1-1'03 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: . RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS—. 8SM 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 "04.AS I be.. 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES igi NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY W 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. 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 best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME G-KE6-ot'Selk. LICENSE#4 6?Ay SI ATURE' MP❑ MGF❑ JP Egg JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME 6<aoelSac-W"nI$"1, See4'(A- ADDRESS 4t SPE-`n8-.4- 44"`"ne~ CITY YI4'R'm°at STATE mA ZIP Oa 6�3 TEI008)-IV -Py3Y FAX CEL O ')179 "(3'( EMAIL SCIezVCoer e- yali0. cow —