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HomeMy WebLinkAboutBLDG-22-004226 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE (January 28,2022 I PERMIT# BLDG-22-004226 Ir_ JOBSITE ADDRESS 210 STATION AVE OWNER'S NAME DENNIS YARMTH REGIONAL SCHOOL G OWNER ADDRESS STATION AVENUE SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL I] RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT 0 PLANS SUBMITTED:YES❑ 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 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 1 OTHER DESCRIPTION:steam kettle 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 ❑ 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 (Troy Gilbert I LICENSE# 25383 SIGNATURE MP❑MGF❑JP© JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: (TROY J GILBERT I ADDRESS. 139 STATION ST, CITY IWAREHAM ISTATE MA ZIP 025711324 TEL I FAX I I CELL I I EMAIL I S31ON M3IA32l NYld #IIWb9d $ :33d ❑ 0 11141N3d 31-11 Sd S3A83S NOIiV011ddY SIHI oN sa, S310N NOI103dSNI 1YNId A1N0 3Sfl d0103dSNI dOd 3OVd SIHl S310N NO1103dSNI SVO HOflO i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM 1-triffj CITY alMDlitt\A MA DATE i /2- 2022 PERMIT# �, Z2 r `wfe,,,, 71 . JOBSITE ADDRESS 210 5 tch on Ave, OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL X RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: C PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 1 FLOOR--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _ , DEDICATED SPECIAL WASTE SYSTEM . DEDICATED GAS/OIL/SAND SYSTEM . DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN . FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR (INTERIOR) _ KITCHEN SINK _ LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET _ URINAL _ WASHING MACHINE CONNECTION _ WATER HEATER ALL TYPES _ a WATER PIPING OTHER S'kearny.eitka X Cafe / K:,'rrhen INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES K NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE � .�•_ aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Ge - . . • 8 C� my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER X AGENT ❑ ``UR • OWNER OR AGENT I hereby cent - that all o - details and information I have submitted or entered regarding this application are true an..-ccurate to the best of m knowledge and that all •lumbi.• ' ork and installations performed under the permit issued for this application will be in corn• ce with all Pe 'n-• • a ision oft - Massachu tate Plumbing Code and Chapter 142 of the General Laws. j ,',,..,"" /il. PLUMBER'S NAME rOy J G1i _ ',-�1.�1 + LICENSE # �35J / IGNATURE T MP ❑ JP ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # CO MPANY NAME Ccotat MChonICaf ADDRESS Z 1 L Fç c,a,n \ JC CITY ___5__ALKC Makth STATE 1-A, Ps ZIP OLOO TEL a)b 1 - 8117 FAX CELL EMAIL