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HomeMy WebLinkAboutBLDG-23-001248 [ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,{) �s CITY YARMOUTH I MA DATE September 08,202 PERMIT# BLDG-23-001248 JOBSITE ADDRESS 120 NANTUCKET AVE OWNER'S NAME BRUNELLE PAUL A TR G OWNER ADDRESS THE PAUL A BRUNELLE LVG TRUST 120 NANTUCKET AVE SOUTH YARMOUTH MA TEL 02664 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS BSM I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE 1 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN 1 POOL HEATER ROOM I 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❑ BOND ❑ OWNER'S INSURANCE JVAIVER: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 Nicholas Gault LICENSE# 16841 SIGNATURE MP© MGF ❑ JP El JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: GAULT ENTERPRISES ADDRESS. 10 Artisan way, CITY Forestdale STATE MA ZIP 02644 TEL FAX 10ELL EMAIL nick a(�,gacltenterpriseslIc.com S310N M31A321 NVId #111%13d $:33d ❑ ❑ 111%13d 3H1 SV SAS N011VOIlddV SIR] oN seA S310N NOI103dSNI IVNId AINO 3Sl210103dSNI 210d 30Vd SIHI S310N N01103dSNI SVJ HJf10N } ''7 MA ACE�U ETT UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ` �6F CITY Yikr."4›... &--(•4;w�- MA DATE41/E- PERMIT 3 '' 2 6/ 1 ~ JOBSITE ADDRESS ;' G C} 4-)A--/ ' C � Ave--- OWNER'S NAME GOWNER ADDRESS SS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL L EDUCATIONAL PRINT OMB-1`RCIA [� [ RESIDENTIAL [� CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: [V PLANS SUBMITTED: YES ❑ NO En" APPLIANCES 7 FLOORS-* 6SM 1 2 3 1 5 6 7 o 9 10 BOILER - — l.I 12 I� LL4 BOOSTER -_� CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER, _ L____ FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE f--"-- GRILE INFRARED HEATER 4 jL E E I V E D n LABORATORY COCKS _.. ��.�- ,__________. MAKEUP AIR UNIT • OVEN I ' SEP 0 8 2 L POOL HEATER -� _ ROOM 1 SPACE HEATER Bt-ti-biNG uPioff< I NT ROOFTOPUNIT uY -- _ TEST _ . . . . .. . . _. .... . .. C UNIT HEATERIft LJNVEI�1TED ROOM HEATER 1---- WATER HEATER - , OTHER 6 6-r` II 1 i INSURANCE COVERAGE q I have a current liability insurance policy or its substantial equivalent which meets theYES requirements of I�GL. Ch. 1�2 N0 ❑ ti I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF CO\'ERA •.BY CHECKING THE APPROPRIATE BOX BELOW i LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND ❑ • OWNER'S INSURANCE WAIVER: I am aware that the licen see does not have the insurance coverage required by Chapter 142 of the c? Massachusetts General Laves, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT El "i_ I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the b e ' and that all plumbing work and installations performed under the permit issued for this application will be in corn liance it II Pertinent rtoof my knowledge Li 4 Massachusetts State Plumbing Code and Chapter •142 of the General Laws. P on of the PLUI��BE -GASFIT"rCR NAME ' LICENSE # �,SE ��, ��� SIGNATURE MP I MGF ❑ JP ❑ JGF ❑ LPGI [ CORPORATION 0 #f PARTNERSHIP 0 # LLC Ej # t t i 4-- 1 ,-1 4—e-- 's L s U 4DDRESSA-r-1 ) 10-‘- _j_COMPANY NAME Q�c f I W �%c CITY ` ,re_s:1 ' 1e - 525-2— STATE Xi( Pc ZIP TEL TEL Ci2C -6 V6 ' 73 Z FAX CELL EMAIL '1 ' Cik.(A. (fe.."-)(6-- f i' c a (ic... c...41; W 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 •