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HomeMy WebLinkAboutBLDG-2-007221 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' BLDG 21-007221 �, CITY YARMOUTH MA DATE June 11,2021 PERMIT# IF— L7z JOBSITE ADDRESS 6 RHODE ISLAND AVE OWNER'S NAME SCIARAFFA MICHAEL TR G OWNER ADDRESS JOHN F BURKE TRUST 48 APPLETON RD AUBURN MA 01501 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL EI PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO El FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE • DIRECT VENT HEATER DRYER • FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN I POOL HEATER ROOM/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 0 BOND 0 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 keith farnham LICENSE# MA SIGNATURE MP© MGF 0 JP❑ JGF 0 LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#I I COMPANY NAME: ADDRESS. 57,Whites Path, CITY South Yarmouth STATE MA ZIP 102664 I TEL 15083986901 FAX CELL EMAIL 1 I 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