HomeMy WebLinkAboutBLDG-22-004080 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY YARMOUTH MA DATE January 24,2022 PERMIT# BLDG-22-004080
JOBSITE ADDRESS 367 ROUTE 28 OWNER'S NAME CAPE COD CHILD DEVELOPMENT PROGRAM IN
G OWNER ADDRESS 83 PEARL STREET HYANNIS MA 02601 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: 0 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 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 ❑ OTHER OF INDEMNITY El 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 Kurt Moody LICENSE# 13706 SIGNATURE
MP❑ MGF 0 JP 0 JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: KURT MOODY ADDRESS. 14 LOOKOUT POINT RD,
CITY PLYMOUTH STATE MA ZIP 023601352 TEL
FAX CELL EMAIL none
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GASFITTING WORK
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Valffi CITY , t `.eir41 C -<i-- MA DATE PERMIT
JOESIT ADDRESS 3c---7 ,/_ % 0�,r OWNER'S NAM .S 5�.�NAME-..) -- G 67�' t,
GOWNER ADDRESS
RESS TEL FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 1--- RESIDENTIAL E
CLEARLY
NEW: ❑ RENOVATION: ❑ REPLACEMENT: E
PLANS SUBMITTED: YES ❑ NO ❑
APPLIANCES 1 FLOOR S-+ BS1v1 1 2
BOILER 1 56 I
9 10 II 12 3 1,,
BOOSTER f
CONVERSION BURNER
COOK STOVE —7- ___________
DIRECT VENT HEATER
1
DRYER - i
FIREPLACE i
FRYOLATOR
FURNACE I ,
GENERATOR _
GRILLER E C
1 V --6-11----=
INFRARED HEATER
LABORATORY COCKS —� • A I - r I
MAKEUP AIR UNIT • ► `�
OVEN
POOL HEATER
•
E o n{� N� I J;
ROOM 1 SPACE HEATER - $„ _
ROOF TOP UNIT
TEST
,1 UNIT HEATER
IJl4VENTED ROOM HEATER
WATER HEATER i
OTHER
\ I I
I
41 l~ I
INSUI ANCE COVERAGE
\ I have a current liability insurance policy or its substantial equivalent which meets the requirements of IUIGL. Ch. 142 YES PrNO
r 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
: LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY H BOND
N ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
t Massachusetts General Laws, and that my signature on this permit application naives 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 and accurate to the best
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision knowledge
edge
Massachusetts State Plumbing Code and Chapter .142 of the General Laws. P on of the
U PLUI��BER-�ASFIT�rER NAME LICENSE LICENSE # I1 10(o SIGNATURE
MP I MGF E JP ❑ JGF ❑ LPGI LJ CORPORATION ❑ #i: PARTNERSHIP 0 # LLC
0 it
COMPANY NAME ' - �L ZV G ADDRESS PV / o'' Pc,'-4- 6-- GZ /
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y
CITY f- A ?4- STATE G �,r,
ZIP c� L �� G TEL S `ir- - a2 r-7
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT it
PLAN REVIEW NOTES
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