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HomeMy WebLinkAboutBLDG-21-004648 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE February 16,2021 PERMIT# BLDG-21-004648 JOBSITE ADDRESS 95 PINE CONE DR OWNER'S NAME HAYES DANIEL F G OWNER ADDRESS HAYES MARCELA M 11 DARLENE DR SOUTHBOROUGH MA 01772 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 1 FRYOLATOR FURNACE GENERATOR 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 John Gilmore LICENSE# 13699 SIGNATURE MP© MGF 0 JP❑ JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: PLEASANT BAY PLUMBING INC. ADDRESS. 43 B Independence Way, CITY Brewster STATE MA ZIP 02631 TEL FAX CELL EMAIL pleasantbayplumbinq(a,comcast.net ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ D FEE:$ PERMIT# PLAN REVIEW NOTES Y --- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _,.. ILO G—zc—oa(-l�y8 =:ii_, CITY VA�Z\.k k["t- MA DATE -- L PERMIT# JOBSITE ADDRESS 9,> i''''t✓N c CCti,i( -- 0\L"0 L OWNER'S NAME i-)1\'L ` �_ GOWNER ADDRESS TEL FAX‘-t4'.fCS TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALp PRINT CLEARLY NEWct3 RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-4 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 ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER rt OTHER 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 THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY f 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 ❑ 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 acid accurate to the t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliange with provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME �1'C "�`)- t E LICENSE#k,,"3 5 SIGN RE MP MGF❑ JP❑ JGF❑ LPG!El CORPORATION Of = Li,k PARTNERSHIP❑# LLC❑# COMPANY NAME \\{--1,Ck \ Q�� �Y ADDRESS ? 6iT'- C.E-�i-N�' �: (23, t-- CITY \b12-6K--=C ,,'t--- STATE `+ "k ZIP C'-)2— (. TEL 7?tf`72 2 W - c/ FAX CELL EMAIL RS � ` 'T � -' t.Ni �kC�i{( C ��