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Home My WebLink AboutBLDG-21-002931 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK — -- CITY YARMOUTH MA DATE November 20,202(PERMIT# BLDG-21-002931 27 � JOBSITE ADDRESS 17 LEGEND DR OWNER'S NAME LANE GERALD T G OWNER ADDRESS COSCO CAMILLE A 140 SOUTH STATE RD BRIARCLIFF MANOR NY 10510 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0 FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER 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 ❑ OWNERS 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 Charles Delvecchio LICENSE# 13269 SIGNATURE MP 0 MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Charles M Delvecchio ADDRESS. PO BOX 719, CITY FORESTDALE STATE MA ZIP[626440702 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 CID - APPLICATION # MASSACH%SET T S UNIFORM APPLICATION FOR A PERNIJT TO PERFORMrt GAS FiTTh'G WORK R' �� Were---0(-7H4 MA DATE I-. 1. —20 PERMIT# BLDG.-Z1J00Z�' � �'h, CITY JOBSI T E ADDRESS ` 11 D s Re. .OWNER'S NAME 6e(1-9 Lz , \ OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[e. PRINT CLEARLY NEW:27 RENOVATION: E REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS-' i BSM 1 2 3 4 5 6 7 8 I 9 10 1 11 12 13 ' 14 BOILER h BOOSTER CONVERSION BURNER I _ _a __� _____ ___i 1 t___ COOK STOVE I i DIRECT VENT HEATER DRYER FIREPLACE ; 4 j FRYOLATOR i ! ! FURNACE I GENERATOR GRILLE _ INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT ( ( ._Ke.,.. ,_ 4� OVEN ; , - -.1 POOL HEATER ! I 1 ROOM / SPACE HEATER i . , , r{ r '' ROOF TOP UNIT f 1----- 1 ,i r_ TEST - - —. I I .;� J..: . _ -i-- I ° JT UNIT HEATER 1 UNVENTED ROOM HEATER t WATER HEATER i I l OTHER I f { + I i I I 1 i l t INSURANCE COVERAGE I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL. Ch. 142 YES I NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M7 OTHER TYPE INDEMNITY 7 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 L I hereby certify that all of the details and information I have submitted or entered regarding this application are true at�d c0rat 'to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp dance rditfi a# ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �LJ L PLUMBER-GASFITTER NAME 1��^ -i S'' � L'eC-y t I & LICENSE # 32(4 SIGNATURE MP �MGF 7 JP fl JGF n LPGI ❑ CORPORATION ❑# PARTNERSHIP E# ❑LLC # ` COMPANY NAME: CO-PL. 41+ ADDRESS «p &ex -75 CIT`! tI7 r'.2�--1-4-7)- I-e__ 1 STATE (\ I) P OZ0-1 Li TEL Cc2 - L:77.--- 1 ) 2. ' FAX ---I. CELL' 12_ JEMAIL I • _ 1 -- -(72_,C) \(-PL" : : THIS APPLICATION SERVES AS THE PERMIT YES NO FEE: $ /