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HomeMy WebLinkAboutBLDG-23-001235 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 2Y i , CITY YARMOUTH kMA DATE September 07,202 PERMIT# BLDG-23-001235 JOBSITE ADDRESS 18 WOLFSON RD OWNER'S NAME Chase Caruso G OWNER ADDRESS 18 WOLFSON RD SOUTH YARMOUTH MA 02664-1346 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 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 1 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 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 Mark Watson LICENSE# 3842 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: MARK D WATSON ADDRESS. 81 CAPTAIN PERRY RD, CITY BREWSTER STATE MA ZIP 026312559 TEL FAX CELL EMAIL pieman835,comcast.net S310N M3IA3H NV-Id #1IW213d $:33d 1INDEd 3H1 SV S3A1,13S NOUVOIlddV SIHJ oN seA S310N NO1103dSNI lVNI AINO 3Sl 210103dSNI 210d 30Vd SIH1 S310N N011O3dSNI SVO HOflO '' 4N.... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Milj-g? Iki,t _ ,�, CITY S 0 l� A DATE7G ~ 22_ PERMIT P # 3 f Z3 JOBSITE ADDRESS I8 LA a L rs G ( RO OWNER'S NAME Chase C�(( U S o G OWNER ADDRESS TEL FAQ; TYPE OR RT OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL rl'-- _ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES — _ NO El APPLIANCES 1 FLOORS-4 SSIv1 1 2 3 4 5 6 7 8 9 10 11 12 13 BOILER 1- BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER, FIREPLACE FRYOLATOR FURNACE GENERATOR QOrr-St 0 I GRILLE r INFRARED HEATER .RECEIVE D LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER • SEP -0 6 2022 J 1___. ROOM l SPACE HEATER - ROOF TOP UNIT 1 i i -att:1G • PA-R T N . TEST ---, Ry•_ . - UNIT HEATER _ - --- UNVENTED ROOM HEATER V WATER HEATER 1 OTHER - 1 INSURANCE COVERAGE I have a current Liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ( NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE r THE TYPE OF CC�\ ERAC , CHECKING TIlE 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 14.2 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER SIGNATURE OF OWNER OR AGENT AGENT '-�� I hereby certify that all of the details and information I have submitted or entered regarding this application are tr a urate t :-the s and that all plumbing work and installations performed under the permit issued for this application will be in co r J edge Massachusetts State Plumbing Code and Chapter -142 of the General Laws. P e ith all P iti t tl�e�l it,t1 PLUMBER-GASFITTEF -AME 0 14 K< b (,'J 1Sz:) . , . 1 LICENSE - � �� SIGNATURE ''Ill MP D MGF JP ❑ JGF E LPGI f l CORPORATION ❑ /f PARTNERS P #M ❑ LLC ❑ # COMPANY NAME R Ks tt-ovvic`- _� t \t/ ADDRESS '3( CA F 0 i 1Z ti) e r y ,- CITY Ci Tel/3 A-- 3 f STATE ,1 A ZIP C 2 6 3 j TEL 2 l 1' FAX F CELL EMAIL ROUGil GAS INSPEa TIOtd NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yee No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • - — — FEE: $ PERMIT# PLAN REVIEW NOTES