Loading...
HomeMy WebLinkAboutBLDG-21-007553 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK °-1 CITY YARMOUTH MA DATE June 28,2021 PERMIT# BLDG-21-007553 Ii_ k, -� 66 RANDOLPH RD OWNER'S NAME Robert Phillips JOBSITE ADDRESS G OWNER ADDRESS 66 RANDOLPH ROAD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 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 , DIRECT VENT HEATER DRYER . FIREPLACE FRYOLATOR . FURNACE 1 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 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 Sean Oleary LICENSE# 3957 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: SEAN F OLEARY ADDRESS. 2 FABYAN RD, CITY PLYMOUTH STATE MA ZIP 023602390 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 '>.. MASSACE-HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t_ i 7R gic �v ��` 4C o�C -Zt- coo 7-,y, CiT( IZIn'1dU/ MA DATE ,. ` PERMIT ,� S53 ADDRESS 6�' JP� RD , OWNER'S NAME t t ---7-a es- &en— JOBSITE � - G OWNER ADDRESS ( ( TEL Ste- . 7- 7OcCFAY TYPE OROCCUPANCY TYPE [-V-N PRINT COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW: 17 RENOVATION: ❑ REPLACEMENT: g2 PLANS SUBMITTED: YES NO ❑ 1 APPLIANCES _I- FLOORS-* BSIvI 1 ? 3 4 5 6 7 B 9 11 12 13 14 i BOILER BOOSTER --� CONVERSION BURNER, COOK STOVE c DIRECT VENT HEATER DRYER 1 FIREPLACE1 II FRYC)LATOR t FURNACE 1 GENERATOR I GRILLE MIIIIII1=11 INFRARED HEATER I R - C- LABORATORY COCKS • I MAKEUP AIR UNIT OVEN I 111 I POOL HEATER _ROOMSPACE HEATERBUI DIN D " • ` _ ROC)F TOP UNIT ByI i WI TEST UNIT HEATER UNVENTED ROOM HEATER I 1 WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MU. Ch. 142 YES �NO l I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE ,APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND n • 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 my signature onthispermit application yJ ive;� this requirement. I I -, CHECK ONE OI L . OWNER 7 AGENT Q .. SIGNATURE OF OWNER OR AGENT t-, I hereby certify that all of the details and information I have submitted or entered regarding this application are true an accurate to the best o y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia a with all Peqbaent pr ' n of the Massachusetts State Plumbing Code and Chapter '1�2 of the General Laws.G /Att /— PLUMBER-GASFITTERLy NAME s� © �� � , � � .. / LICENSE � � SIGNAT RE MP ❑ MGF n JP n JGF Vr LPGI n CORPORATION ❑ it PARTNERSHIP ❑ # LLC E #: COMPANY NAME \ AU 1- 1-74 C - ADDRESS o — r4&V,P- / RO . CITY 1 v!/k 001 l+ STATE ��,A� nn �vA• ZIP 0(-)36 V TEL FAX CELL °Th " / EMAIL illOgaifs Aourt0-40--ii-r- c C --(iiictr(e 45-1) 7 coo.. F:�i1G�I GAS Ir��PEG I�r�r rfC3 TES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT :❑ ❑ • FEE: $ PERMIT It PLAN REVIEW NOTES