HomeMy WebLinkAboutBLDG-21-006898 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
10r=!' CITY YARMOUTH MA DATE May 27,2021 PERMIT# BLDG 21-006898
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JOBSITE ADDRESS 5 CEDAR ST OWNER'S NAME adam tate
G OWNER ADDRESS MA 01803 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO 0
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
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 El
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 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 Herbert Healis LICENSE# 20177 SIGNATURE
MP 0 MGF 0 JP El JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑#
COMPANY NAME: HERBERT M HEALIS ADDRESS. 78 STUDLEY RD,
CITY S YARMOUTH STATE MA ZIP 026642906 TEL
FAX CELL EMAIL hhealis( yahoo.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
i. t_1=,'� CITY: Yarmorth MA. DATE:5/26/21 PERMIT#QL-De LI-Wb9'WY
JOBSITE ADDRESS: 5 Cedar St OWNER'S NAME: Tate
GOWNER ADDRESS: Same TEL: FAX:
TYPE OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO❑X
APPLIANCES? FLOOR Bsmt 1 2 3 4 5 6 ' 7 8 9 10 11 12 13 14
BOILER
BOOSTER ,
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER lr
DRYER
FIREPLACE I
FRYOLATOR j
FURNACE
GENERATOR
GRILLE T
Lt INFRARED HEATER
l:^ LABORATORY COCK
Cv MAKEUP AIR UNIT
OVEN ,
POOL HEATER
ROOM/SPACE HEATER--.1 _I ROOF TOP UNIT I
' TEST _
UNIT HEATER
f,L) UNVENTED ROOM HEATER
WATER HEATER 1 .
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 ® OTHER TYPE INDEMNITY ❑ BOND ❑ I
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 ail Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, ,/ /C if
PLUMBER/GASFITTER NAME: Herb Healis LICENSE#20177 �y SIGNATURE
COMPANY NAME: ADDRESS:78 Studley Rd
CITY: Yarmouth STATE: Ma ZIP: 02664 FAX:
TEL: CELL'08 776 5495 EMAIL: hhealis@yahoo.com
MASTER 0 JOURNEYMAN[X] LP INSTALLER 0 CORPORATION 0# PARTNERSHIP❑# _ LLC❑#
c hi}}/C- ADDze SS : _ _ _____