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HomeMy WebLinkAboutBLDG-22-004199 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH I MA DATE January 27,2022 PERMIT# BLDG-22-004199 JOBSITE ADDRESS 16 WIDGEON LN OWNER'S NAME Brian Manqaudis G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL � RESIDENTIAL El 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 FRYOLATOR _ FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN 1 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 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 Daniel Melanson LICENSE# 12926 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: [DANIEL E MELANSON ADDRESS. 41 TWICKENHAM XING, CITY W BARNSTABLE STATE MA ZIP 026681153 TEL FAX CELL EMAIL danotis11 vahoo.com S310N M3IA321 NVId #1IW213d $:33d ❑ ❑ 1111d3d 3H1 SV S3AH3S NOIlVOIlddV SIHl oN saA S31ON NO1133dSNI 1VNld AINO 3Sl d0133dSNI 210d 3OVd SIHI S310N NO1133dSNl SVO HOl021 1 • 1 : _ �� i VFHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1.L:Ji g,� CITY Aril/ Li 1 1I MA DATE ,/Z "I, PER 2 -- c1 / pry 1• I Z PERMIT .1# Z 1 i 5 BAN ���-� � _ / Ell,e._..,,f. A DR.SS �(d t CI eu�1 v. OWNER'S NAME l Iv G r TEL 5c TEL g. � .� OCCUP.ANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL Z�, CLEARLY NEW: ❑ RENO'\/ATION: ❑ REPLACEMENT: L`T PLANS SUBMITTED: YES ❑ NO APPLIANCES 71. FLOORS-4 BEM 1 2 3 4 5 6 BOILER 7 ° 9 11 '1' 12 I; 1, BOOSTER I____ CONVERSION BURNER COOK STOVE r----- , __________ DIRECT VENT HEATER DRYER FIREPLACE — i FRYOLATOR _ FURNACE GENERATOR GRILLE _____I INFRARED HEATER LABORATORY COCKS ! MAKEUP AIR UNIT OVEN r i 1 POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST . UNIT HEATER - _ 'INVENTED ROOM HEATER WATER HEATER V"OTHER --; __ _, I I INSURANCE COVERAGE l have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 14 YES el10 ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY D BOND, OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurancei Massachusetts General Laws, and thatsignature on thispermit application naives this coverage required by Chapter 142 of the my ` J lip waives SIGNATURE OF OWNER OP, AGENT CHECK ONE ONLY: OWNER �AGEI �' ❑ `-"L• I hereby certify that all of the details and information I have submitted or entered regarding this application `- and that all plumbing work and installations performed under the permit issued for this application will be in complire anceand w.ac all ro the best of knowledge '` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. P nce w' all Pertinent provision of the PLUMBER-GASFIT'f EP, NAME LICENSE SIGNATURE MP l MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ F PARTNERSHIP ❑ 41: LLC ❑ COMPANY NAME Pt4 n fl Jfri5U y' P 4. ADDRESS CITY L), 64ro 4 L / - ) i C4 5 I'--/, STATE .4 ti ZIP TEL W ec TEL —�_MS-. FAX F. CELL EMAIL '6 1 i i I 6_4(.)47 , ( o c", 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