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HomeMy WebLinkAboutBLDG-21-004635 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE February 16,2021 PERMIT# BLDG-21-004635 ill. JOBSITE ADDRESS [35 OYSTER COVE RD OWNER'S NAME BEELER JOHN H G OWNER ADDRESS REELER BARBARA M 35 OYSTER COVE RD SOUTH YARMOUTH MA 02664-2320 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL III PRINT CLEARLY NEW: ❑ 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 1 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❑ 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 michael pierce LICENSE# 34718 SIGNATURE MP❑MGF❑JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑a LLC 0# COMPANY NAME: ADDRESS. CITY west yarmouth STATE TT ZIP 02673 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY SO AA-. r !h PJi MA DATE PERMIT JOBSITE ADDRESS 6 ySi'ey-(bl e. I ! OWNER'S NAME ��Cob C%I t- GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL Er-- PRINT CLEARLY NEW: ❑ RENOVATION:Lid REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO E APPLIANCES 7. FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE r 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 f OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE 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 CHECK ONE ONLY: OWNER ❑ AGENT El 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 I Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ PLUMBER-GASFITTER NAME LICENSE# c/ ]7 soli SIGNATURE MP❑ MGF❑ JP Qr JGF ❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Pie.c-11) l• r1'lljIY15)�t'_/C'VC=4/Ut.t� ADDRESS tl /4—civCP C. CITY 'v >4- N./6i r C; STATE Z � ZIP !`r),(� 7_ TEL 7�7q 7�FAX CELL EMAIL f)/ r-e. �� i��� S- r'Voce, i GM4.