Loading...
HomeMy WebLinkAboutBLDG-21-005194 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `-7 CITY YARMOUTHi/L MA DATE March 12,2021 PERMIT# BLDG 21-005194 tI� g ,/ JOBSITE ADDRESS 51 LONGFELLOW DR OWNER'S NAME amy dwyer G OWNER ADDRESS 17 STONE RIDGE RD BREWSTER NY 10509 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑ 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 GENERATOR GRILLE _ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER _ ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 • 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❑ 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 Stephen Ewing LICENSE# 15281 SIGNATURE MP© MGF 0 JP 0 JGF 0 LPG! ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: STEPHEN D EWING ADDRESS. 140 WHITE MOSS DR, CITY MARSTONS MLS STATE MA ZIP 026481080 TEL FAX CELL EMAIL steve anedgewaterplumbinq.com 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 :Z\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK " (_;, CITY Yarmouth a MA DATE D112/21 PERMIT# ILL D G 2 - 06 SDI 9 I JOBSITE ADDRESS 51 Longfellow Drive I OWNER'S NAME Amy Dwyer GOWNER ADDRESS TELr508-294-6287 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL T RESIDENTIAL, PRINT CLEARLY NEW:r---1 RENOVATION: v REPLACEMENT:[L PLANS SUBMITTED: YES i NO❑ APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 ' 10 11 12 13 14 BOILER .--_ - __- . BOOSTER i _ CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER — FIREPLACE II FRYOLATOR -li ' FURNACE _ ,y- — J _ r + GENERATOR - GRILLE 7- INFRARED HEATER i LABORATORY COCKS MAKEUP AIR UNIT OVEN --- POOL HEATER j ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER 11 iL UNVENTED ROOM HEATER 1 - WATER HEATER _ L OTHER _ i E _ r---- in 1 INSURANCE COVERAGE I have a current IiabilitYinsurance 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 Q OTHER TYPE INDEMNITY 7 BOND I 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 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. . 5c� PLUMBER-GASFITTER NAME I Stephen D.Ewing I LICENSE# 15281 I SIGNATURE MP v MGF❑ JP _] JGF❑ LPGI❑ CORPORATION Q#[3672 PARTNERSHIP❑# LLC❑# COMPANY NAME: Edgewater Plumbing&Healing ADDRESS[P.O. Box 656 CITY Sagamore _ 1 STATE FMB ZIP 02561 TEL 508-317-9680 FAX CELL 508-737-0077 EMAIL steve@edgewaterplumbinginc.com