Loading...
HomeMy WebLinkAboutBLDG-23-004792 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March01,2023 PERMIT# BLDG-23-004792 JOBSITE ADDRESS 6 HERITAGE DR OWNER'S NAME DEREK MOSS G OWNER ADDRESS WENDY MOSS 6 HERITAGE DR WEST YARMOUTH 026730000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0 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 1 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 El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q 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 1 have submitted or entered regarding this application are true and accurate to the best of my knowledge and that at plumbing work and Installations performed under the permit issued for this application wit be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Stephen Soares LICENSE# 15782 SIGNATURE MP©MGF El JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN M SOARES ADDRESS. 30 Oak Street, CITY New Bedford STATE MA ZIP 02740 TEL FAX CELL EMAIL S3lON M3IA31:1 NVId #tIWb3d $ :333 ❑ ❑ ±I1A1H3d 3Hl SV S3A2l3S NOI1VOIlddV SIHl oN seA S31ON NO1133dSNI 1VNI3 /ONO 3Sfl a)103dSN1 end 30Vd SIHl S310N NO1103dSNI SVO HOfOb M. II • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT # L "73 00 v#99), JOBSITE ADDRESS _6 c A . -c --- OWNER'S NAME _P_e_cele OWNER ADDRESS _ --_— — _ TEL 7^)1 of fL., FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: v� RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO APPLIANCES Z 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 L' GRILLE INFRARED HEATER _ LABORATORY COCKS RECEVED MAKEUP AIR UNIT OVEN -4 :,?Y POOL HEATER A ' AAR O 2021 ROOM / SPACE HEATER ROOF TOP UNIT R a jai rllG 1) -HRTMF[_T TEST _ BY 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 P'1VO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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. ---_ 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 complia e with all Pertinent vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE #/5>8'2 SIGNATURE MP "MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC E'# i o?x COMPANY NAME _ S tki_c u�.c, ( f/�+ � GCS_ ADDRESS 3_4) o _1C CITY 3ed_rei-tri -- STATE_ /`' 4_ ZIP d 2 7_cka TEL -- FAX --- CELL YoK_1 _,��--- EMAIL f' vas --- 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