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HomeMy WebLinkAboutBLDG-21-006990 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Faa CITY YARMOUTH MA DATE June 02,2021 PERMIT# BLDG-21-006990 JOBSITE ADDRESS 17 LEGEND DR OWNERS 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 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0 FIXTURES FLOORS—a 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 1 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 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 0 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 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 Mark Moran LICENSE# 20786 SIGNATURE MP❑MGF 0 JP© JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME: (MARK R MORAN I ADDRESS. 16 BRAMBLE BUSH DR, CITY IFORESTDALE I STATE MA ZIP 026441017 TEL FAX CELL EMAIL 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 - MASSACHUSETTS U IF APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK !=r3-''' j1,7-44g? . 114. _P CITY( ac/2-7-0 a 1‘1A DATE PERMIT at D G- Z( - o e c.,5 5 O JOLSIT ADDRESS 7e7 OVVIJER'S NAME .r,C,f' Z4,,r7_re9. --' GOWNER ADDRESS TEL FAX TYPE OROCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL [ RESIDENTIAL Z1/ PIUNT - -. TmNOVATI ' 0_-: :: RS'PLACSVEM -, .- t ,.... _ ,..- -- _.. PtAN S SUEslf D: 'Yin 17. N0 APPLIANCES 1 FLOORS—F BSMM 17 3 1 5 6 7 8 9 10 11 12 •13 1 BOILER BOOSTER { CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER J � DRYER 1 FIREPLACE I FRYOLATOR FURNACE GENERATOR GRILLE / T INFRARED HEATER I i LABORATORY COCKS 7: - I ' b MAKEUP AIR UNIT - I i OVEN i r I4i# ; i i i POOL HEATER ROOM / SPACE HEATER ' - . • • ' • , i-1,14 .0' -71 , ROOF TOP UNIT a . TEST �--_; ' � �....-.._.. _ __ �. . --_ _ UNIT HEATER UNVENTED ROOM HEATER WATER HEs`\TE R 1 OTHER I L_I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of N1GL. Ch. 142 YES NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 7 BOND ❑ 1 I OWNIER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massathusetts General Laws, and that my signature on this permit application naives this requirement. I CHECK ONE ONLY: OWNER P AGENT ❑ 1 SIGNATURE OF OWNER OR AGENT j I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat- the best of my knowledge I `, and that all plumbing work and installations performed under the permit issued for this application will be in compii.1 e with - "ertinent rovision of the Massachusetts State Plumbing Code and Chapter . 2 of the General Laws. � 4'PLUMBER-GASFITFER NAME W4/ i/ 0e LICENSE 1;6713,6 . ./".j/.1 1 L CE SE 5 NATO , MP ❑ MGF n JP JGF LPGI E. i'ORP �k-,-,-TION D IF PARTNERSHIP #� LLr (1 # COMPANY NAME 4 rL1GRE`SS ADDRESS /-' .--) CITE' (-0i-e, er STATE / IP 0_,. 6Ø/ TEL I r FAX CELL EMAI 1/446J v r I w_ l i I • .6t b 4 � ,ram : . I rw I co 1 1 i • O 4 I G 2 D CO E °- ft r- w � m EA .- �, er — co• Lai fs. LU GA co C.9 Q 0.1 Q. u, Iii I U- • I n • V - O I 1 I