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HomeMy WebLinkAboutBLDG-22-003134 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK j CITY YARMOUTH MA DATE December 01,2021 PERMIT# BLDG-22-003134 JOBSITE ADDRESS 20&22 ATLANTIC AVE OWNER'S NAME VIRTOM LIMITED PARTNERSHIP G OWNER ADDRESS 2 ATLANTIC AVE SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: m 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 2 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 El 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 IVirgilio Silva I LICENSE# 31395 SIGNATURE MP 0 MGF 0 JP❑ JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: IVIRGILIO SILVA I ADDRESS, 1155 SUDBURY LN, CITY IHYANNIS I STATE MA ZIP 026012462 TEL FAX I I CELL I I EMAIL Ivirgiliomoa(1a.hotmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT [] El FEE: $ PERMIT# PLAN REVIEW NOTES ft7ASSACE-6USETTS LINJIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK W .7 ‘4tif=J �,�U Ai MA DATE (� K. . ,6. CITY 1 /Qf� Z PERMIT zz- 3/3�j h Ors, JOBSITE ADDRESS 2 2 4 L 4N><in, A V-e OWNERS NAME I/1419A,A ,L P GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL pgNT ,. ❑ RESIDENTIAL❑ CLEARLY NEW:Lv�/ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO[2-- APPLIANCES 1 FLOORS-4 BEM 1 2 3 4 5 6 7 o 9 10 11 12 •13 14 BOILER ----_ BOOSTER CONVERSION BURNER __L_ COOK STOVE t r:, r. _�__s „.? -- DIRECT VENT HEATER i • DRYER j - - t FIREPLACE - u t.t 8 ; 22 FRYOLATOR FURNACE T s -. - I Luii..�: L-, .R 1'?, .:,4T GENERATOR L ry, --, GRILLE INFRARED HEATER LABOPJJTORY COCKS �� MAKEUP AIR UNIT - OVEN POOL HEATER ROOM f SPACE HEATER ROOF TOP UNIT TEST . . �. . —, UNIT HEATER UNVENTED ROOM HEATER — WATER HEATER OTHER INSURANCE COVERAGE Er I have a current liability insurance policy or its substantial equivalent which meets the requirements of WIGL.Ch.112 YES LE NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 • I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the b st of r v Knowledge ` •- and that all plumbing work and installations performed under the permit issued for this application will be in compliance w' inent provision or he Nz--` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -, PLUMBER-GASFITTER NAME V/46;4,it) ,c Li/4 LICENSE#34.7 q c SIGNATURE MP ❑ MGF❑ JP IE(JGF ❑ /LPGI El !CORPORATION❑# PARTNERSHIP❑�l LLC❑# COMPANY NAMES;WA Litry lrV/v v KP4-1--) tiG ADDRESS /55- S(..0 6C.A Y L/ti-e CITY 1`y.4-4VA/1'5 //.. STATE i�a ZIP �2L.G/ TEL FAX CELLlY4360/ 76' EMAIL✓Je-si4-< 16401C 44i/ '(%OA 0.* . 9 v' ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE Q LX FINAL INSPECTION NOT++ L Yes No THIS APPLICATION SERVES AS THE PERMIT (l (l FEE: $ PERMIT ft PLAN REVIEW NOTES I