Loading...
HomeMy WebLinkAboutBLDG-22-001295 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'fir CITY YARMOUTH MA DATE September 07,202 PERMIT#k_ BLDG-22-001295 r JOBSITE ADDRESS 38 DANBURY ST OWNER'S NAME Kevin Driscoll G OWNER ADDRESS 38 DANBURY ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 DIRECT VENT HEATER DRYER 1 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY BOND 0 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 Simmons I LICENSE# 116259 I SIGNATURE MP© MGF ❑ JP 0 JGF 0 LPG! 0 CORPORATION 0#I I PARTNERSHIP ❑# Lc ❑#I COMPANY NAME: I I ADDRESS. 14 Jeannes Way, I CITY IForestdale I STATE MA ZIP 102644 I TEL I I FAX 1 I CELL I I EMAIL IdevlinsimmonslIcna,gmail.com I S310N M3IA321 NVId #1101213d $.33d ❑ 0 11V d 3H1 SV S3Aa3S NOI1VOIlddV SIHl ON se1 S31ON NO1103dSNI 1VNId AlNO 3Sl 2J0103dSNI 210d 30Vd SIHI S310N NO1133dSN1 SV0 HOl021 Ste.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,.' � 1 C `(D �X V�fit/ MA DATE 1✓3 -Z) PERMIT# o S )3 2 i•�L JB9TE ADDRESS ?v� Pa CJ Li( LA 54-- e.e OWNERS NAME �P l.ly\ V krN.CU�_1 OWIj=RADDRESS cW PC O yr% S -e_t TEL 5 Q643I 5-1/Q FAX B ILDIiNG uENA . FMENT 81, __TYPE PRI OCCUP._,.JCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL®— PRINT CLEARLY NEW:[9:----RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO Cp--- APPLIANCES 1 FLOORS- 1 2 3 4 5 6 B 9 10 11 13 1 R BOILER BOOSTER CONVERSION BURNER COOK STOVE j DIRECT VENT HEATER DRYER �� FIREPLACE FRYOLATOR _J FURNACE ____I GENERATOR 1 GRILLE . ■ ■ i INFRARED HEATER 1 LABORATORY COCKS MAKEUP AIR UNIT OVEN ( 1 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 E1E ❑ 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 ❑ J SIGNATURE OF OWNER OR AGENT r. 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. L1 PLUMBER-GASFITTER NAME LICENSE#((aZ5-G' SIGNATURE MP ‹IGF El JP El JGF❑ LPG'❑ CORPORATION El# PARTNERSHIP❑# LLC aff 3i ?S COMPANY NAME -Ni tNA SklAtA^- i s I---L-C- ADDRESS 41 3 'avl S Q6-- ��//�� CITY "1 -5-a-Cc� STATE /R� ZIP O - 4W TEL -(9#- 2-cgQ FAX CELL EMAIL IN LI v$(Vt4U QKs LL-C&A4 k r c9v'1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT (J • FEE: $ PERMIT PLAN REVIEW NOTES