HomeMy WebLinkAboutBLDG-22-003715 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
' c CITY YARMOUTH 1 MA DATE January 04,2022 PERMIT# BLDG-22-003715
JOBSITE ADDRESS 114 LILY POND DR I OWNERS NAME ISue ellen Ford J
G OWNER ADDRESS 14 LILY POND DR SOUTH YARMOUTH MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW 0 RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED:YES❑ NO❑
FIXTURES FLOORS—r BUM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
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 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 El NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El 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 at 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 we be in compliance with an Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Andrew Leighton LICENSE# 16130 SIGNATURE
MP El MGF❑JP 0 JGF❑ LPGI El CORPORATION El# PARTNERSHIP ❑# LLC❑#
COMPANY NAME ANDREW R LEIGHTON ADDRESS. 20 Brewster Rd,
CITY 1W Yarmouth I STATE MA ZIP 026735706 TEL
FAX CELL EMAIL halloilcompanYdtSmail.com
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= LI E UNI/FORiti APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-'-- i CITY VD . A Ht`<C_)c.ot MA DAM -3 ' 2- PERMIT
f JOSS E ACCRaSS /V /i Z '�'td` }Dr 1 _ N -S E
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4, 4 OWNER ADDRESS t• , FAX
TEE OR } _ ,�
t PRINT OCCur::1�;0 --;- _ COMMERCIA1 EDUCATNA. RESIDENTIAL
CLE.A.RLY NE': RENOVATION: ! FD-TEEN-7: V - PLANS SUBMITTED: YES NO V
APPLIANCES 1 FLOORS 3SM s I 2 3 i f 5 1 6 7 ! 9 10 1 1 1 ; t2 13 14
BOILER ><4 • s I H
? t
BOOSTER i ? s _i- i
' CONVERSION BURNER - - E I t
I COOK STOVE t .1 € I E I : tt t
t r • t c
•
DIRECT
VENT
C� j � { ( F 1
DIREC i 7 ENT HEATER EER j -I t J I F i I L 4
IRYER i j i ; s i I I
L1
FIREPLACE I t 4 t fi _ I 4
I FURNACE -+ _ t - ? t i I I L
I;EI ERA T OR 1 }
i t , ! ; 1 s i t
GRILLE • I i I
INFRARED HEATER I F t E t I I • _ -
I.ABOIATORY COCKS = i ._ i 1 - i
MAKEUP AIR UNIT t 1 I I e _
OVEN - .t - - --- 1 f t { ..In : .
POOL HEATER ` ; ` _ V. j i _
ROOM!SPACE HEATER _ . f
ROOF OP UNIT ► t i i L
TEST j y _ t ---
UKIT I- AT' i 4 # - . - �.�-T
UNV_NTED ROOM HEATER r _ ._
WATER HEATER - 1 i - `• . '
_ S • 1, i
I • • - -
OTHER k t tt 1
E t i j t `
+ 4 f { I
T ; t
t
( 1 t
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T F I - i
' INSURANCE COVAt YES
I have a current iiabi e insurance Policy or it sub:tn a eglivalentwt the requirements of MGL.Ch.l4
I IF YOU CHECKED YES,RASE INDICATE THE TYPE OF COVERAGE EY CHECKING THE ORATE BELOW
LIA ILT( INSURANCE POLICY V OT hP' , : INDEnrry BCND
OWNER'S INSURANCE V .JV'E.R.: I am wars that the licensee does not have e i age coverage required by Chapter 142 of the
liassachuseits Genera' Laws,and that my signature on this parr&application wai this requirement.
. , CHECK ONE 0 : OWNER AGENT
I-- SIGNATURE OF OWNBR OR AGENT • lTh
I hereby cerffy that all cf fne details amt.irtorrncr: I have subraided or antared reaar i aaig:trIcafion� arm . - _- * of mY Knowledge
and that all pt +o.-
g I<=-.d p,.�:rr ei i tsit€SSUat€far this appn n?AIbr in pan �'TFs.' - �,, . 1'_• • Lithe
Massactase s State Pftrabina Code and Chap r 142 of the Ganerai Laws. /
f
t PLUMBER-GASP T ER NAME ANDRCW y-IGI-::CN LICENSE ielfo-M SIGNATURE
I
rP 1 MGF III~ JGF Li--GI CORPORATION ' # 3734C PAIZINERSHIP # LLC
COMPANY NAME_ HAil OIL COMPANY INC. ADDRESS 415 ST 1
CITY SOUTH DENNIS STATE MA T, .o • TEL 508-398-383 i
FAX 508-384-3055 CELL I✓3 1� fiiIzilcom yagrnaii.ccrn
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