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HomeMy WebLinkAboutBLDG-21-005943 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK fkErn BLDG-21-005943 �, CITY YARMOUTH MA DATE April 14,2021 PERMIT# .,,{- '� JOBSITE ADDRESS 49 JACQUELINE CIR OWNER'S NAME NOLAN CAROLYN T G OWNER ADDRESS CONNERY FRANCIS 130 SACRAMENTO DR LEOMINSTER MA 01453 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ 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 , DIRECT VENT HEATER . DRYER 1 , FIREPLACE 1 . FRYOLATOR FURNACE 1 . GENERATOR , GRILLE 1 INFRARED HEATER , LABORATORY COCKS , MAKEUP AIR UNIT . OVEN 1 POOL HEATER , ROOM/SPACE HEATER , ROOF TOP UNIT TEST 1 , _UNIT HEATER . UNVENTED ROOM HEATER , WATER HEATER 1 , OTHER , OTHER DESCRIPTION:BBQ Grill is outside 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 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 Eric whiteley _ LICENSE# 15920 SIGNATURE MP❑ MGF © JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: W Vernon Whiteley Inc ADDRESS. 28 Village Landing, CITY West Chatham STATE MA ZIP 02669 TEL 5089451100 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