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HomeMy WebLinkAboutBLDG-21-006269 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE April 29,2021 PERMIT# BLDG-21-006269 FF_ JOBSITE ADDRESS 87 MASSACHUSETTS AVE OWNER'S NAME FINELLI THOMAS G OWNER ADDRESS FINELLI KAREN M 172 MIDDLE RD SOUTHBOROUGH MA 01772 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS—0 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/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 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 Kurt Moody LICENSE# 13706 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: KURT MOODY ADDRESS. 14 LOOKOUT POINT RD, CITY PLYMOUTH STATE MA ZIP 023601352 TEL FAX CELL EMAIL none 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 CID - APPLICATION # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY / MA DATE (---/ -- Lc-7 _ / PERMIT # eisj i)_ !!!JOBSITE ADDRESS r4v•41OWNER'S NAME -7A-%-e.) -5• `� � /� ASS l�-�4-1t- �; � t-S OWNER ADDRESS TE- FAX G TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL R PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑ APPLIANCES Z FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER - -� CONVERSION BURNER R E COOK STOVE DIRECT VENT HEATER 2P DRYER '21 FIREPLACE - Wit FRYOLATOR BUI D PAk I iv'LINT 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 INSURANCE COVERAGE I have a current liability_insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES r1NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY j OTHER TYPE INDEMNITY n 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. 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 ssued 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 l�Lei'7` `.4v,0 FrL LICENSE # SIGNATURE MP Mi4GF n JP ❑ JGF ❑ LPG' n CORPORATION ❑ # PARTNERSHIP❑# LLC ❑# COMPANY NAME: " „4:,Gz f H ADDRESS pi- 0/.._ /C_o,.. led ccl CITY P( y STATE (,.s2 ZIP V2 i ci TEL �CJ c � ..�. FAX CELL EMAIL THIS APPLICATION SERVES AS THE PERMIT YES _ NO FEE: $