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HomeMy WebLinkAboutBLDG-22-000181 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kr, ''��`i_- CITY YARMOUTH MA DATE July 12,2021 PERMIT# BLDG-22-000181 F JOBSITE ADDRESS 452 ROUTE 28 OWNERS NAME T&C Holdings G OWNER ADDRESS 452 ROUTE 28 WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Q RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO 0 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 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND El 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 David Houde LICENSE# 16673 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: MCDONNELL MECHANICAL SERVICES IN ADDRESS. 79,School Street, CITY 'West Dennis STATE MA ZIP 026702445 TEL 5083940005 FAX CELL 5082463152 EMAIL ROUGH GAS INSPECTION NOTES I THIS PAGE FOR INSPECTOR USE ONLY 1 FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ FEE:$ PERMIT# PLAN REVIEW NOTES CI L._t,. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK w :� H C(TY 4,44, r 4 7 G �� F G-ZZ - �v�� Sl - ., �'" MA DATE PERMIT l-1� / o '`cc No /c'" , Q 1 JOBSITE ADDRESS el C� � H4 % S�` OWNER'S NAME 74 C / /AtW 1 ' y ,- OWNER ADDRESS TEL FAX V tYPA b . OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RES IDENTIAL—p : OMMERCIA �� EDUCA"I IONAL 1 RESIDENTIAL _, NEW: RENOVATION: ❑ REPLACEMENT:P' PLANS SUBMITTED: YES [ NO APPLIANCES 1 FLOORS-- BSIvi 1 ? 3 4 5 6 7 9 10 '11 12 •I; 1% BOILER BOOSTER - CONVERSION BURNER �� COOK STOVE / DIRECT VENT HEATER DRYER FIREPLACE i FRYOLATOR ' FURNACE GENERATOR GRILLE INFRARED HEATER j LABORATORY COCKS ? 1 MAKEUP AIR UNIT j OVEN i POOL HEATER ROOM ; SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER 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 Li NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA . Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' OTHER TYPE INDEMNITY fl BOND El 1 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the l Massachusetts General Laws, arid that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT 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 myknowledge 1 ; and that all plumbing work and installations performed under the permit issued for this application will be in co + . cc with all Pe ' eit provision of the ` 14 J Massachusetts State Plumbing Code and Chapter .14 • of the General Laws. PLUMBER-GASFITTER NAME Oa i/Y a (-le 1 LICENSE �/6617 SIGNATURE I P ,/iGF (l JP [l JGF [7 LPGI [l CORPORATION l f PARTNERSHIP ��// deECOMPANY NAME P-,4 f' / � � N ADDRESS �l 6 &CQe1 /�-r/(. CITY gi /- 6c,f C i STATE 4 ZIP 0) 6 1— TEL C-O $ -d Cl)- 6 yt? FAX CELL EMAIL IUQ LlCi1 /104,-(/‘ dxa -► 1 i I CO 0 I Z I - I E-, 1 fat G1 Z 1 I I i I Z a t El I w o w Z. I F a w Cn_ en w ? I -.. - I LU o L w o I i S LU L— U t I Cn 1 C) 1 7- Ii )L 1 {�� K� Cn I -4 1 P4 ii