The URL can be used to link to this page

Home My WebLink AboutBLDG-21-004455 \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k1,„ • CITY YARMOUTH MA DATE February 05,2021 PERMIT# BLDG-21-004455 JOBSITE ADDRESS 194 BERRY AVE OWNER'S NAME WHITE RICHARD A G OWNER ADDRESS WHITE JOAN P 6189 SHOREWOOD COURT LISLE IL 60532 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 1 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 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND 0 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 Adam Larsen LICENSE# 33750 SIGNATURE MP❑ MGF ❑ JP❑ JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADAM LARSEN ADDRESS. 8 FARNHAM ST, CITY BOSTON STATE MA ZIP 021192908 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK V:-I -7--7- CITY: -1(C ( N�;i AL.` MA. DATE /- r`/ L( _ PERMIT#BL'-'b4 `l CS- JOBSITE ADDRESS: 1 i.(-- : 1 C� (\ I `(7. OWNER'S NAME V\I rl\ \,k.,i-R- G OWNER ADDRESS: L _ / TEL: '76 4:119 4(-FAX: TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ APPLIANCESZ FLOOR...* Brant 1 2 ' 3 4 5 6 7 r 8 9 10 11 12 13 14 BOILER _ _ BOOSTER CONVERSION BURNER , COOK STOVE I . DIRECT VENT HEATER DRYER FIREPLACE _ _ FRYOLATOR _ 1 FURNACE t GENERATOR GRILLE V> INFRARED HEATER , W LABORATORY COCK _ _ MAKEUP AIR UNIT 4 OVEN �— � . , ii.; POOL HEATER �+� ROOM/SPACE HEATER A f ' `l ROOF TOP UNIT s 1 a 4 TEST Z UNIT HEATER + Bl I11 ,'H tT writ PTr 1.4.1 UNVENTED ROOM HEATER _ WATER HEATER i I INSURANCE COVERAGE I have a current litiWitty insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO 0 If you have checked YE ,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0 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 0 SIGNATURE OF OWNER OR AGENT 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 Portent provision of the Massachusetts Statee..Plumbing Code and Chapter 142 of the General Laws. �///,,,;,-- PLUMBER/GASFITTER NAME: irk LICENSE#` "SIGNATURE/COMPANY E; Y" `O /Jq()Cir-- ''t DRESS: t (ik") --iff--I / a' CITY: . '.' 0Y52-1-0-3,2--- f1� I ZIP: (3 67 F J� S FAX TEL: CELL: 1 `j'�� ()� UAIL: VA/td46 4�� Gc"i u\ MASTER 0 JOURNEYMAN 0 LP INSTALLER l❑ CORPORATION 0# P Ip AR�'N RSH ❑# LLC❑# c Sri L. ADD e.ss