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HomeMy WebLinkAboutBLDG-21-006136 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE (April 23,2021 I PERMIT# BLDG-21-006136 JOBSITE ADDRESS 12 SHAKER HOUSE RD OWNER'S NAME MCCABE KATHLEEN E G OWNER ADDRESS 19 DONNA RD HOLLISTON MA 01746 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ 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 1 FIREPLACE FRYOLATOR FURNACE 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 0 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 at 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 at 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 Walter Lolko LICENSE# 7568 SIGNATURE MP©MGF❑JP 0 JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME: Falter J Loiko —I ADDRESS. 198 OLD COLONY RD, CITY HYANNIS STATE MA ZIP 026014627 J 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 `s ;/, G ''' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I CITY: VAr2.�C7f f MA. DATE t�•�; / PERMIT# JOBSITE ADDRESS: 7,2 f l�A-f t._ 4-ife 'o OWNER'S NAME: 41--`73-" /) ae'.f4' GOWNER ADDRESS: /4 ;/-?4,;, j D .wt-/c7G4Al.17P TEL:(Ov jq 2 i`cibc 7 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL El EDUCATIONAL El RESIDENTIAL 0- PRINT CLEARLY NEW:❑ RENOVATION:❑- REPLACEMENT:❑ PLANS SUBMI f I ED: YES❑ NO❑ APPLIANCES FLOOR--, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE t DIRECT VENT HEATER DRYER FIREPLACE _ _ FRYOLATOR FURNACE GENERATOR GRILLE lr} INFRARED HEATER i LABORATORY COCK MAKEUP AIR UNIT _ � OVEN POOL HEATER ROOM/SPACE HEATER -.I ROOF TOP UNIT ' TEST UNIT HEATER i,U UNVENTED ROOM HEATER WATER HEATER 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 have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY El OTHER TYPE 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 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. ,A it-,,� ,�f �1�7/mac, _ PLUMBER/GASFITTER NAME: C.'A-c 7 72 1---- %JtC LICENSE# 75-W SIGNATURE COMPANY NAME: 9.rrI/7r -n ,,Tr# ADDRESS: , ff e z cvzTriv—ir-D CITY: F.{' e'2-hi S STATE: ?','-- ZIP: (s,2 e FAX: TEL: CELL: EMAIL: t-r— .2 �,1. 2 €, l,)---: L_ l:/1 MASTER[❑ JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LC El# E h) ic. ,9DJ2c Ss :