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HomeMy WebLinkAboutBLDG-23-002659 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ki- CITY YARMOUTH ejMA DATE November 14,202', PERMIT# BLDG-23-002659 JOBSITE ADDRESS 124 PLEASANT ST OWNER'S NAME CAVANAUGH ROBERT J G OWNER ADDRESS CAVANAUGH NANCY A 124 PLEASANT ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ 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 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 0 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 David Townsend LICENSE# 16945 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPGI 0 CORPORATION 0 # PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 271 Main St., CITY Plympton STATE MA ZIP 02367 TEL FAX CELL EMAIL D.TOWNSEND89 an.OUTLOOK.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 ._ --T. MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM OAS FITTING WORK `. CITY: 9 r NIl1%J i-h MA DATE; l//7/2 Z POW'I .108SfTE ADORES& 1,32,V Pie-e. ,- . 5+ men NAME /litrevL y Cott,R-Ni)v cr tie- J OWNER ADDRESS; /2 y Rt„s.., 4 c-- Ta: SS2a 27L t)f FAx: TYPII OR oc rANcy TYPE OOIimmak 0 7TIONAL 0 MINIMAL PRINT CLEARLY NEW:0 RB4OVATION:❑ REPLACN IT: FANS stoma YES 0 NO❑ APPLIANCES FLOOR Banc 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 800STER CONVERSION BURNER COOK STOVE T DIRECT VENT HEATER — _ - r DRYER ' FRYOIATOR 4 FURNACE GENERATOR GflLLE VI I*RAJ ER HEAT _ - W LABO RAT0R'Y000K - V MAItBJP AR UNIT - ' - , POOL HEATER ROOM!SPACE HEATER J ROOF TOP UNIT - - - - TE>sT t _ , z UNNTT HEATER 14J ty1VBifH)ROOM HEATER WATER HEATER 1 INSURANCE COVERAGE I have a correct bog insurance poky or its wEe4ndd equivalent which malls the requirements of MGL at 142 YES 014) ❑ r you hove checked yffl,please tame the type of coverage by decking Im appropriate box bebw. LIABILITY INSURANCE POUCY [3 OTHER TYPE INDEMNITY ❑ 8010 ❑ MEWS INSURANCE WAIVER I am awe that Os Immo figanafze ties insurance coverage required y Otos 142 digs IYsssdasaab Ge ne si Laws,and that my signature on this permit application vim Iles requirement. CHEClt ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby uerfob that al of the dell and informoko I have ebi s4(or antersdj rag rdng this**akin are hue end mural,lo ihe beet of ny Modulo end teat al plertinp work and Mnibne palmed wider tea;omit lad for Ns applksion w11 be In a#t al Pantwtt provWort of the MeeeachueeMs Staff PksvI*t Code ell Moir 142 of the Genial tewe co cc-T-9A,-�/ �� v PLUMEERJGASFITTER tIAME 044.,40 Tan/A/SS/VC LICENSE _ _/(p sis--SIGNATURE COMPANY NAME: /Oc '/V i/t49 P7 H La. ADDRESS a 7/ MA/ cmr: P-ymPre)fIZ STATE: �?ft ZIP Dn23 G 7 FAX TEL: 7(V 357-2vc:VCe.L; OWL d, 6 3n SC._d 8? 0,,fluoic _cam MASTER ETIOIRNEY14AN L7 LP WSIM1E t❑ CORPORATION❑: PARTNERSHIP❑e uc 3(T.Co b cluck. AlVite ss: _