Loading...
HomeMy WebLinkAboutBLDG-23-004793 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK BLDG-23-004793 CITY YARMOUTH MA DATE March 01,2023 PERMIT# JOBSITE ADDRESS 123 TRADERS LN I OWNER'S NAME BARRY DONALD P G OWNER ADDRESS 23 TRADERS LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT.❑ PLANS SUBMITTED:YES 0 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 © NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY El BOND ❑ OWNERS 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 Soares LICENSE# 15782 SIGNATURE MP©MGF 0 JP 0 JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME: STEPHEN M SOARES ADDRESS. 30 Oak Street, CITY New Bedford STATE MA ZIP 02740 TEL l FAX CELL EMAIL S310N M3IA321 NVld #iJVJd9d $ :33d ❑ ❑ IIW2J3d 3H1 SV S3AH3S NOLLV011dd`d SIHI oN saA S310N NO1103dSNI 1VNId AlNO 3Sl HOJ 3OVd SIH1 S310N NO1103dSNI St/0 HJflO MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a _ CITY ide4401.'4 MA DATE 3 -/-- a 3 PERMIT # 6t)4/2 JOBSITE ADDRESS Q?3 -1'A1, 1d_04-e OWNER'S NAME __Uor/6-1d 3A rt y OWNER ADDRESS _ TEL _— _ FAX --- TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL -' PRINT CLEARLY NEW: [ 4- RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO APPLIANCES -1 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 �---- MAKEUP AIR UNIT R E C E I V E r:5, OVEN 1471-- ?61 4(64 POOL HEATER M () 1 123 ROOM / SPACE HEATER ROOF TOP UNIT vTUENT TEST UNIT HEATER `'y 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 L0 ❑ 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER El 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 comp ance with all Pertin t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' PLUMBER-GASFITTER NAME LICENSE #/ r2' Z SIGNATURE MP //MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC YY� � y COMPANY NAME _S►'a_p 'A —7- ik,411 y, ADDRESS 3 p, 14-L/ --- CITY � � a -- STATE H.4 .. ZIP _o_d� 2 TEL ---- -- FAX --- -- - CELL s o.8_ 6 -±64/S' EMAIL ,Shs_, �O �/ CoAi --- - 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