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Home My WebLink AboutBLDG-21-002930 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE November 20,202( PERMIT# BLDG-21-002930 JOBSITE ADDRESS 3 JERUSHA LN OWNER'S NAME RUSSO JOHN M G OWNER ADDRESS 353 WASHINGTON ST WINCHESTER MA 01890 l TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 PRINT CLEARLY NEW: Cl 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 1 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❑ 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 Steven Traill LICENSE# 21392 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEVEN J TRAILL ADDRESS. 178 MALDEN ST, CITY MALDEN STATE MA ZIP 021486519 TEL 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 e f r CITY l; I2/h t ry MA DATE /1 — /2 —2c) - PERMIT#8 41-1T JOBSITE ADDRESS S -Jl'�L fY? &V- OWNERS NAMEI1''i4Ai �� r GOWNER ADDRESS /V r042//(J/?>1..Z/ Ai) ' TEL o17- C//Zel/FA.x TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: g' REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO E APPLIANCES 1 FLOORS—+ EiSM 1 2 3 l 5 6 7 8 9 10 11 12 13 14 BOILERBOOSTER ■ ■■■ { CONVERSION BURNER COOK sTovE i I .! DIRECT HEATER ' ; DRYER I FIREPLACE ! FRYOLATOR FURNACE I INFRARED HEATER LABORATORY COCKS . MAKEUP AIR UNIT OVEN L POOL HEATER • ROOM I NM : c . .. i ROOF r UNIT .- �Ii' �` UNIT HEATER I I, 171ytI INVENTED ROOM HEATER • i • - __•_OTHER . . l INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of.IGL.Ch.142 YES ❑ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Rs OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSU NCE WAIVE l am aware that the licensee does not have the insurance coverage required by Chapter 142 of the - Massachusetts .r .ral Laws,• that my signature on this permit application waives this requirement. �� ll � CHECK ONE ONLY: OWNER ❑ AGENT ❑ •`.. SIGNATURE OF OWNER OR AGENT r'1-• I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate}b the best of m knowledge `- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with ally ent provist of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ; �/ • ,s1�•„� 4t GGGG `` PLUMBER-GASFITTER NAME LICENSE# a213(I,;2 y SIGNATURE MP ❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑#i PARTNERSHIP❑# LLC❑# COMPANY NAME -,57t'i.,t'r jp^a/ I,4- ADDRESS �J CITY ret a.L''4-'/I STATE /f ' • ZIP 1Z175 W. TEL 2 /-V7y"77J7 FAX CELL EMAIL �--- i I ...'....."\ G°t ""•••••\ 0 I C...) Ni If1 0 I I i I I i n I V1 C, �, Lii 4 i 1 = . . 0 LU . - . . . g Lu LIA us GA co C P 7.4 `J LJ [-1 a_ u3 tii I I 1 o o 7 o • I N ! G red I tk - V I i I t