HomeMy WebLinkAboutBLDG-22-000588 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
R `,a Is CITY YARMOUTH _I MA DATE August 02,2021 PERMIT# BLDG 22 000588
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JOBSITE ADDRESS 28 MARY DAVID RD UNIT 60A OWNER'S NAME mary barrett
G OWNER ADDRESS 7 WESTOVER SOUTH DENNIS MA 02660 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 1
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 r,garding 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 Paul Viera LICENSE# 26989 SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: IPAUL A VIERA ADDRESS. 3 SHADY DR,
CITY HARWICH STATE MA ZIP 026452930 TEL
FAX 1 CELL EMAIL paulsplumbing20na vahoo.com
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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%�;���,,� CITY MA DATE PERMIT# 3i 0 ' - zZ-°ucJ 5Y'3
JOBSITE ADDRESS& rAA2A5._ oA-Lick OWNERS NAME Ma 11t. ectirr-0-
GOWNER ADDRESS TEL FAX
•
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: 0 REPLACEMENT:tr- PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS--I BEM 1 2 3 4 5 6 7 8 9 10 '11 12 13 1!
BOILER —'--
BOOSTER
CONVERSION BURNER
COOK STOVE
• DIRECT VENT HEATER
DRYER
FIREPLACE —
FRYOLATOR
FURNACE —__I
GENERATOR I
GRILLE l
INFRARED HEATER
LABORATORY COCKS .
MAKEUP AIR UNIT
OVEN I'�
POOL HEATER • - 1
ROOM I 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 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 I 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.
CHECK ONE ONLY: OWNER ❑ AGENT El
SIGNATURE OF OWNER OR AGENT
,.i1 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 corn 'th all Pertinent provision of the
`' Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP ❑ MGF❑ JP3d JGF❑ LPGI ❑ CORPORATION❑If PARTNERSHIP 0#r LLC❑#
COMPANY NAME PPJc P«t 1.---,: vlci ADDRESS 3 v-u�i_Lt pi
CITY (PC1\ I `- CJA- STATE ie)(1 el. ZIP (37L e ( TEL ?C�� `f 3 2 -I 1 3 i
FAX CELL7�7%i JS- ,�12- EMAIL v "-' g Lk•Vi•Se5` -)a. ace CC4-1
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