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HomeMy WebLinkAboutBLDG-22-01366 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK l _ CITY YARMOUTH MA DATE September 09,202 PERMIT# BLDG 22 001366 JOBSITE ADDRESS 156 SWAN LAKE RD OWNERS NAME CIFELLI GEORGE W G OWNER ADDRESS CIFELLI ANN 156 SWAN LAKE RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑ PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO III FIXTURES FLOORS--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER • CONVERSION BURNER COOK STOVE 1 , DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR FURNACE , GENERATOR , GRILLE r INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT , OVEN POOL HEATER , ROOM/SPACE HEATER ROOF TOP UNIT h 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 Justin hogg LICENSE# 32412 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: Justin Hogg Plumbing&Heating Inc. ADDRESS. 63 swift brook rd, CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 5082373694 FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ cJ' Cl/ct2L Gr/ FEE:$ PERMIT# PLAN REVIEW NOTES