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HomeMy WebLinkAboutBLDG-23-000156 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kgif CITY YARMOUTH MA DATE July 11,2022 PERMIT# BLDG-23-000156 JOBSITE ADDRESS 95 PINE CONE DR OWNERS NAME HAYES DANIEL F G OWNER ADDRESS HAYES MARCELA M 11 DARLENE DR SOUTHBOROUGH MA 01772 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: ❑ 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 1 DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR FURNACE GENERATOR _ 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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 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 Steve gilmore LICENSE# 13699 SIGNATURE MP©MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: PLEASANT BAY PLUMBING INC ADDRESS. 43 b independence way, CITY Brewster STATE MA ZIP 02631 TEL FAX CELL EMAIL PLEASNTBAYPLUMBING(a.COMCAST.NET S3 LON MRIA321 NV ld #U V'J H3d $ :333 ❑ ❑ .III 2d 3E11 SV S3A2i3S NOLLV3llddd SIHl ON SO), S310N NOI103dSNI lYNId AINO 3Sf1210103dSNI 210d 30Vd SIHJ S310N NO1103dSNI SYJ HJf Od . t>MIASSAC;HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING «F�_ A :.- 7,�- WORK .i-- 4, • - .-C-FFY MA DATE 7jio /2-2..._. PERMIT # Z3 Cu C (3) , JUL, ,� IT AD RESS CIS Ptx1C- Gpso 6- OWNER'S NAME \ 6-- BGUL MiN ' 4 DURESS TEL TEL FAX ByrvP—r$ s-- - PRINT UGC* TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NE'JV: ❑ RENOVATION: 0' REPLACEMENT: ❑ PLANS SUBMITTED: YES a NO ❑ APPLIANCES 1 FLOORS-4 BS M 1 2 5 F BOILER7 8 s 1 l"1 12 I; 1_ BOOSTER CONVERSION BURNER, COOK STOVE `-`H� - DIRECT VENT HEATER r DRYER, I l FIREPLACE I FRYOLATOR — FURNACE GENERATOR GRILLE INFRARED HEATER --- LABORATORY COCKSi______� MAKEUP AIR UNIT OVEN I POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT - TEST NIT HEATER V - . . ---• • • • I UNVENTED ROOM HEATER 1--- WATER HEATER OTHER 1 i - I I INSURANCE COVERAGE I 1 I have a current liability � insurance policy or its substantial equivalent which meets the requirements of NIGL. Ch. 142 YES, 0 NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND El • OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter Massachusetts General Laws, and that mysignature on this permit application gives this requirement. Y 142 of the CHECK ONE ONLY: OWNER 0 SIGNATURE OF OWNER OR CAGENT ❑ A,ENT -: I hereby certify that all of the details and information I have submitted or entered regardingthis ap li and that all plumbing work and installations performed under the permit issued for this applicationcation will be in tr d tot best of my f theknowledge Li j Massachusetts State Plumbing Code and Chapter 142 of the General Laws. corn lie h I, • ent provision or the PLUMBER-GASFIT-FER NAME �, �� ��� �� c LICENSE # t 3(0� SIG ATUR,E MPtR MGF E JP ❑ JGF ❑ LPG' ❑ CORPORATION / # 3(oy,V COMPANY NAME Pk E ksku�, '3 ,� .� PARTNERSHIP 0 �� LLC ❑ # uv-t. t - C• . ADDRESS L{ -1- C- 6,16C-A1(- , U... 04- CITY 1 STATE V�� ZIP O 14, k TEL 179 ' 7 Z FAX CELL EMAIL E4t-r1/4)tis1fO(k- L'u-1/4\4i; t9. c COo,cA S ��.. .�- ROUGH GAS II SPECTIOtd NPTE,S THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT# PLAN REVIEW NOTES