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Home My WebLink AboutBLDP&G-21-001023 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE August 28,2020 PERMIT# BLDD7-21-001023 JOBSITE ADDRESS 256 PLEASANT ST OWNER'S NAME CARLSON RAGNAR W G OWNER ADDRESS CARLSON ANN MARIE 256 PLEASANT ST SOUTH YARMOUTH MA 02664-4557 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL Ej PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 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 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 Brian Hibbard LICENSE# 11977 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: BRIAN S HIBBARD ADDRESS. P.O.Box 429, CITY S YARMOUTH STATE MA ZIP 02664 TEL FAX CELL EMAIL capecodplumbinqayahoo.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 UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY Sl%t,-74 y/2,14'-'l0,,) MA DATE 0/Z (>Z U PERMIT# 2 ✓ JOBSITE ADDRESS ZS-4 P/e4J441-7 57 OWNER'S NAME 4N.Ve /21i .,G C',s,jiu.✓ GOWNER ADDRESS J-Ain fL TEL SCE -77 0- / 14 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDU ATIONAL ❑ RESIDENTIAL D" PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO APPLIANCES 1 FLOORS-I BSM 1 ( 2 3 _ 4 5 l 6 [ 7 8 1 9 1 10 I 11 12 13 14 BOILER r 1i4 BOOSTER CONVERSION BURNER I COOK STOVE DIRECT VENT HEATER I DRYER L FIREPLACE FRYOLATOR _ FURNACE GENERATOR GRILLE INFRARED HEATER I — LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER I ROOF TOP UNIT AU() �' ?L 2'° TEST _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER .� 1 OTHER 1 I ! INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [g NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 1 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 ' all ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r ie PLUMBER-GASFITTER NAME 3 /$,) ,4 , 64 rd LICENSE# 1//7 7 SIGNATURE MP ["MGF❑ JP❑. JGF❑ LPGI ❑ CORPORATION El PARTNERSHIP❑# LLC❑# COMPANY NAME CAP C.S P1�1h Al 4SAxi ADDRESS 3A?c Li Z<j CITY 1117 L D tnfiJ i f STATE /i - ZIP b 2. 6' o 6 TEL LcbJ L 2 Le FAX CELL EMAIL (p J Aiv h+S i.1 g ,yc A ao, / I