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HomeMy WebLinkAboutBLDG-21-006495 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK T �, CITY YARMOUTH MA DATE May 10,2021 PERMIT# BLDG 21 006495 FI� s, JOBSITE ADDRESS 47 DANAS PATH OWNER'S NAME Robert Alexander G OWNER ADDRESS MA 02492-3427 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 POOL HEATER 1 • 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 0 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 Thomas Roche LICENSE# 11635 SIGNATURE MP© MGF ❑ JP❑ JGF 0 LPG! ❑ CORPORATION❑# PARTNERSHIP El# Lc ❑# COMPANY NAME: THOMAS J ROCHE ADDRESS. 550 MAIN ST,#28 CITY WEST DENNIS STATE MA ZIP 026702206 TEL FAX CELL EMAIL i 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 '�' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Pi 11-I t j l' �, -���H� CIT`S ,s'` 5 (�L�- L0 G— 2( Oo(� ci S .6i MA DATE 7 P._RIvIIT Y JOBSITE ADDRESS v 2 _6� 1--: l (>„ k OWNER'S NAME _6 /f- t4•�-it .,/"' OWNER ADDRESS TEL FAX y, TYPE RT OR OCCUPANCY TYPE COMMERCIAL 7 EDUCATIONAL I— RESIDENTIAL W--'"" AT . ❑ tACfi, E'f 'I": ( ' LAI8 8U> 1 (`i `C 1 ` J APPLIANCES -.l FLOORS--. BSM 1 ? 3 1 5 6 7 8 9 10 11 12 , BOILER IJ �-BOOSTER — CONVERSION BURNER COOK STOVE DIRECT VENT HEATER —j i DRYER FIREPLACE FRYOLATOR I ' FURNACE GENERATOR I GRILLE I I INFRARED HEATER I LABORATORY COCKS MAKEUP AIR UNIT OVEN i POOL HEATER ROCOM / SPACE HEATER ROOF TOP UNIT TEST - • --- - .. - -. ..-. . .. - - - UNIT HEATER UNVENTED ROOM HEATER I I WATER HEATER , OTHER f dc / I , t--- 1 �� .i.r cr Calf JSId L pi ptd INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIGL. Ch. 142 YES O ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachu:.etts General Laws, and that my signature on this permit application waives- this requirement. i ., CHECK ONE ONLY: OWNER ❑ AGENT E •� 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 I '` and that all plumbing work and installations performed under the permit issued for this application will be in compliance ►ith aWertinent provision of the Massachusetts State Plumbing Code and Chapter '142 of the General Laws. �� is � i J r PLUMBER-GASFITTER NAME ti� rLICENSE # �'�43 C--- SIGNATURE MP TC9 MGF ____, JP ❑ JGF ❑ LPGI (l CORPORATION ❑ # PARTNERSHIP ❑ i LLC COMPANY NAME (2-& -A- /74 ADDRESS S . �` 1 .� r`-- f. CITY I,,v-e_ J STATE ZIP l 1- 0 TEL ELS23 FAX CELL EMAIL RO� UGI GAS INSFE IIOrd NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL IPI I'EC 1 �1NOTES Yes No THIS APPLICATION SERVES AS THE PEPik1IT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES • • i