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HomeMy WebLinkAboutBLDG-20-003166 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =' -- CITY YARMOUTH MA DATE December02,201E PERMIT# BLDG-20-003166 JOBSITE ADDRESS 389 WHITES PATH OWNER'S NAME ANGELL HELEN T G OWNER ADDRESS C/O PLEASANT ACRES LLC 336 MAPLE ST MANSFIELD MA 02048 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Q , RESIDENTIAL 0 PRINT j(OUP/C CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ -uDi` Or 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 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 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 El 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 Justin Hogg LICENSE# 32412 SIGNATURE MP 0 MGF❑JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: JUSTIN S HOGG ADDRESS. 25 PITCH PINE RD, CITY BREWSTER STATE MA ZIP 026312348 TEL FAX CELL EMAIL /JIJ' ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT CI ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 67,1— d I