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HomeMy WebLinkAboutBLDG-23-005585 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK p ,s CITY YARMOUTH MA DATE April 07,2023 PERMIT# BLDG-23 005585 JOBSITE ADDRESS 233 PLEASANT ST OWNER'S NAME GRIMES THOMAS A G OWNER ADDRESS CIO STAGER NANCY H&JAMES E 233 PLEASANT ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 111 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 2 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 1 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 Michael Pasic LICENSE# 11512 SIGNATURE MP❑ MGF © JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: I ADDRESS. 60 Clamshell Point Lane, CITY Cotuit STATE MA ZIP 02635 TEL FAX CELL 7748367804 EMAIL 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 UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK qt--Wif "^ CITY\,ii r Nl,Ol.l. MA DATE 7.3 _ I C' Z 3 D 0 558' FRiJI T JORSITE ADDRESS 2.. 3 Q,Q,Iis[),-;. OWNER'S NAME '��(),[as A. GOWNER ADDRESS TEL FAQ: TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALQ PRINT CLEARLY NEV, RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 1 i BOILER BOOSTER CONVERSION BURNER COOK STOVE - DIRECT VENT HEATER —j DRYER ' —, FIREPLACE FRYOLATOR FURNACE . GENERATOR Z GRILLE INFRARED HEATER LABORATORY COCKS 1 MAKEUP AIR UNIT --( OVEN i POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT ' TEST UNIT HEATER ' UNVENTED ROOM HEATER - WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES`Q„•NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC'etb 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 waived this requirement. CHECK ONE ONLY: OWNER AGENT ❑ J SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application t and ccur , t est of my ,nowledge `- and that all plumbing work and installations performed under the permit issued for this application will be in m 'anc with I e ' bprov ' of the szt Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \ is 1 PLUMBER-GASFITTER NAME • LICENSE# SIGNATURE M 0011 MGF❑ k JP ❑ lip LPGI CORPORATION Olt PARTNERSHIP❑## LLC❑t# COMPANY NAME v \ ,L. 7'� 'l �`` ADDRESS k '0 - C.:1)X), �ivJ CITY t7,. 1U._ STAT ZIP (--to ' ) -) TEL/7 ' �b ` W FAX CELL EMAIL V"t M4)°°L -L0'''') • ROUGH GAS INSEECTION NOTES THIS;PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • • FEE: $ PERMIT# PLAN REVIEW NOTES