HomeMy WebLinkAboutBLDG-21-001264 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Vs) CITY YARMOUTH MA DATE September 11,202 PERMIT# BLDG-21-001264
JOBSITE ADDRESS 12 ALBION ST OWNER'S NAME !JOHNSON NANCY L
G OWNER ADDRESS PO BOX 342 HYANNIS MA 02601 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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
FRYOLATOR
FURNACE 1
GENERATOR
GRILLE
INFRARED HEATER _
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOMISPACE 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 El BOND 0
OWNERS 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 LICENSE# SIGNATURE
MP 0 MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME: AOC h 0E"S SA N AZ I I r ADDRESS.
CITY STATE ZIP TEL
FAX CELL 7711 J.e1 4 EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
t 5 S i a �l Il! I.2 c z-c THIS APPLICATION SERVES AS THE PERMIT El 1:1
FEE: $ PERMIT#
PLAN REVIEW NOTES