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HomeMy WebLinkAboutBLDG-22-007052 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _....................... u 1-1 CITY YARMOUTH MA DATE June 06,2022 PERMIT# BLDG-22-007052 ` ,,,, JOBSITE ADDRESS 95 LEWIS RD OWNER'S NAME TUCKE CATHERINE M TR G OWNER ADDRESS 20 MARIE AVENUE CENTERVILLE MA 02632-3732 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 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 ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY El 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 BRADLEY TOMASETTI LICENSE# 16544 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# _ PARTNERSHIP ❑# LLC ❑# COMPANY NAME: TOMASETTI PLUMBING ADDRESS. 103 UNION ST, CITY YARMOUTH PORT STATE MA ZIP 02675 TEL FAX —I CELL EMAIL Itomasettiolumbingna gmail.com S310N M3IA32f NVId #LIIJH d $:33d ^'1!S3! 5 33W 0+,7 ❑ ❑ 111N?J3d 3H1 SV S3A213S NOIlVOIlddV SIHI 5.5.7 h z1'44 V3S / ON SaA S310N N01103dSNI IVNId AlNO 3Sf1 HOi3 dSNI NOd 30Vd SIHl S31ON NO1103dSNI SVO HOfON '' MA SSACHUSETT S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING �1�. „�s WORK ��✓� . t J yc,e' 4i `) MA DATE t„ Alt (lef PERMIT2 2- -2(-) 5 z c • JOBSITE ADDRESS / ' L i 4_ ; L A o4 OWNER'S NAME �• •' i y. c kt ________ G OWNER ADDR ESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL'� ❑ AlIONAL ❑ RESIDENTIAL ri CLEARLY NEW: I71/ RENOVATION; 0 REPLACEMENT: C PLANS SUBMITTED: YES 0 NO 0 APPLIANCES 1 FLOORS-I BSM 1 2 3 a 5 6 7 8 9 10 11 12 13 1 BOILER BOOSTER CONVERSION BURNER l 11 COOK STOVE I DIRECT VENT HEATER DRYER, ._J I FIREPLACE FRYC)LATOR I FURNACE —I-- - GENERATOR . GRILLE INFRARED HEATER 1 LABORATORY COCKS ,--- i MAKEUP AIR UNIT OVEN l v ❑ y I POOL HEATER i ROOM ! SPACE HEATER 0 �jQ ROOF TOP UNIT I -----,_____ TEST B ILDING UE 3ART ENT ..... UNIT HEATER _. .._. _ B ' — UNVENTED ROOM HEATER WATER HEATER I OIHER - - I I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIIGL. Ch. 142 YES c❑-f�0 ❑ I IF YOU CHECKED YES, PLEASE INDICATETYPE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ElBOND ElI I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1 Massachusetts General Laws, and that my signature on this permit application waive;: this requirement. I. ' CHECK ONE ONLY: OWNER ❑ AGENT ❑ • 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 •,` 11 Massachusetts State Plumbing Code and Chapter .142 of the General Laws. Y PLUh�SER-GASFITTEF, NAME r �, �1 � 9 LICENSE i �f` � -�------_ r�j' 70 4 1 t s •e � LICENSE #`�., 5, /,- / SIGNATURE MP 0/MGF ❑ JP ❑ JGF ❑ .LP GI ❑ CORPORATION 0 li PARTNERSHIP 0 # LLC� ❑ # COMPANY NAME / 01 -.4, s efir Pict-44 4,:‘.5 ADDRESS / 0 3 (ir 4 ,t,a S /— CITY :•-'^-, o IA A,1---- STATE 4 ZIP .02, ‘ 7)_- TEL '7r 92z. - Cf FAX CELL EMAIL /0/4•1 4 5 elhJ f�el t I t 61. q 641 i ir3S 5--° ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes N THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT# PLAN REVIEW NOTES • •