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HomeMy WebLinkAboutBLDG-23-006085 C,, - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Chsu? CITY YARMOUTH MA DATE [May 04,2023 PERMIT# BLDG-23-006085 0.1 j:, I, . JOBSITE ADDRESS L PINE GROVE VILLAGE 1 OWNER'S NAME ZIRBEL DONNA J TR G OWNER ADDRESS 10 PINE GROVE VILLAGE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 1 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 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 0 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 Keith Farnham I LICENSE# 11601 SIGNATURE MP 0 MGF❑JP❑ JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME: SOUTH SHORE HEATING&COOLING I ADDRESS. 157 White's Path, CITY South Yarmouth I STATE MA ZIP 02664 TEL FAX CELL I EMAIL info(a,southshoreheatingcoolinq.com 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 MASSACHUSETTS UNIFORIIII APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK D tt —) B1D61- Z3 -dim,�0g� V-f.t YO0CrY\011.`i' Th MA. DATE: )l ! PERMIT# �.... � CITY;JOBSITEADDRESS: I 21 r12. Grod� OWNER'S NAME; b3"-- Zi C. be_i . • G OWNER ADDRESS: `D — TEL: 7�9DA-WiogAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL 0 RESIDENTIAL ' PRINT CLEARLY NEW; 0 RENOVATION: E REPLACEMENT: PLANS-SUBMITTED: YES 0 NO ff:( S .:APPLIAN C.ES1 FLOOR-4 ...Bsmt. '1 2 3 4 6 :6 ,7.. . 8 9 10 11 i 2- 13 14 . BOILER BOOSTER • CONVERSION BURNER _ _ COOK STOVE - - - - .DIRECT VENT HEATER ._.. 'DRYER . FIREPLACE _ . FRYOLATOR . FURNACE .... ..._. i GENERATOR _ . GRILLE - • . - INFRARED HEATER _ LA ORATORY COOK _ -. • MAKEUP AIR UNIT n ' OVEN ._ .... POOLHEATER ..... . T. ROOM 1 SPACE HEATER -�:,} 'ROOFTOP UNIT - TEST , _ !� `.... 'UNIT HEATER R E IC E IN ' t. UNVENTED ROOM.HEATER al -- WATER HEATER MAY 0 4 2023 _ , . . '...' • rum DING DE.PARTMEt\T INStiRANCE COVERAGE • BY. ._.-- --- - , I haVea Current liability insurance policy or its.substantial equivalent which meets the requirements of M . . , 142 YES NO 0 If you hive checked YES, please indicatet:he:type of coverage by checking the.appropriate box below. LIABILITY INSURANCE POLICY i OTHER TYPE 1NDE,NINITY 0 BOND ❑ OWNER'S INSURANCE WAIVER; I airs 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: MER 0 AGENT [ . SIGNATURE OF OWNER OR.AGENT - . . . hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and a urate the bes s •'y ' :- Knowledge and•that•all plumbing work and installations performed under the permit issued for this application will be in pliant: i .a •ertin provision of the Massachusetts State.Plumbing*Code and Chapter 142 of the General Laws. ,r PLUMBERIGASFITTER NAME .ikt'AI`urflhaill .LICENSE#. 11Q I _ SIGNA RE COMPANY NAME 50 elbre. iAfalln3 (4 CCItr15,ADDRESS: 5-3 f 1-1-@15 -Poo-N CITY: 5 V )®I t h . . STATE: & ZIP: C a lt 4 ? FAX: J C} '` 60 ,aL I . TEL:50g%s3913— (C9L. I CELL: . . . EMAIL; .c r 5ne, Sou,S141311cNe hko r'roc d 8 rb o 4,cr i MASTER(JOURNEYMAN E LP INSTALLER : CORPORATION d 31cAS C- PARTNERSHIP ❑# LLC : #