Loading...
HomeMy WebLinkAboutBLDG-23-004621 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK --IS CITY YARMOUTH MA DATE February 21,2023 PERMIT# BLDG-23-004621 ZigJOBSITE ADDRESS 23 LEWIS BAY BLVD OWNER'S NAME GALLAGHER BRIAN E G OWNER ADDRESS GALLAGHER JENNIFER A 2 OLD HARRY RD SOUTHBOROUGH MA 01772 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ 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 1 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 1 OTHER DESCRIPTION:fire pit • INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND El 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 Anson Celin LICENSE# 32655 SIGNATURE MP 0 MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ANSON CELIN ADDRESS. 26 Capt.Blount Rd, CITY South Yarmouth STATE MA ZIP 02664 TEL FAX CELL EMAIL ansoncelin(@Nahoo.com 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 r-Wf CITY 4' c t4 MA DATE 2 PERMIT# Z 3 - 4� JOBSITE ADDRESS 2 3 LF hris Otlif , 1_t,p OWNERS NAME /3(/G'-) G /,a jAer G OWNER ADDRESS 2 3 LrW S134 H OD TEL Ov--37G FAX FAX TYPE OR OCCUPANCY TYPE COMMIE CIAL EDUCATIONAL PRINT ❑ ❑ RESIDENTIAL Fr- CLEARLY NEW:❑ RENOVATIOI REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑ APPLIANCES 7 FLOORS—+ BSM 1 2 3 1 5 6 7 o 9 10 11 12 13 14 BOILER ■—� BOOSTER CONVERSION BUR1dEP, ■ ■■■ ■ ■ COOK STOVE DIRECT VENT HEATER _ DRYER FIREPLACE l FRYOLATOR FURNACE GENERATOR GRILLE ! INFRARED HEATER I LABORATORY COCKS `! MAKEUP AIR UNIT OVEN I POOL HEATER L__ ROOM; PP.CE HEATER ■■■■ ■ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER j WATER HEATER —�— OTHER ;t✓, e INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE II4DENINIT' ❑ 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 best of my knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in compli nee with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. % .5-k___ Cc/ PLUMBER-GASFITTER NAME LICENSE#3ZC-5.j— SIGNATURE MP ❑ MGF❑ JP I2 JGF❑ LPG'❑ CORPORATION 0 Li PARTNERSHIP❑# LLC❑# COMPANY NAME (CI I r1 Punih1nt, ADDRESS C ,'j 1.-1 (3,citr0 CITY STATE m A ZIP 4."2-6-C t_/ TEL $ 2.. :f FAX CELL EMAIL AnSi1-4_tl ROUGIi GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • • FEE: $ PERMIT t# PLAN REVIEW NOTES • •