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HomeMy WebLinkAboutBLDG-23-004304 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK din',�, CITY YARMOUTH MA DATE February 03,2023 PERMIT# BLDG-23-004304 "n; ,�' JOBSITE ADDRESS 120 HOMERS DOCK RD OWNER'S NAME Doreen Delmonaco G OWNER ADDRESS 120 HOMERS DOCK RD YARMOUTH PORT MA 02675-1010 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 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 1 DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR FURNACE 1 1 GENERATOR 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER 1 OTHER DESCRIPTION:outdoor grill INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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 INhan Nguyen I LICENSE# 15210 SIGNATURE MP©MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME NHAN H NGUYEN ADDRESS. 1284 Bridge St, CITY IRavnham ISTATE MA ZIP 027671975 TEL FAX I CELL EMAIL hiohtek2010WWvahoo.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 ��Cf MASSACFIUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • _, - CITY y� _���U f� MA DATE 3' 2 2 PERMIT 'f ! 3 2 I 2 )BSITE ADDRESS (. F► 0 lrl4 S 0 bC'r- (2"-�OWNER'S NAME OC)QGO ) 1)-- c B P . ..-rTtWdBR DDRESS GlA 'L(7 TEL S-VV— G`4Z — 17(GFn.,"'�(3 uy -- PRINT OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL(kl) CLEARLY NEW:❑ RENO'VATION:yr REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ No❑ I APPLIANCES FLOORS—} BSM 1 2 3 !Is 6 7 El 9 10 11 12 •13 14 . BOILERCOOK STOVE I CONVERSION BURNER BOOSTER I DIRECT VENT HEA,TER DRYER FIREPLACE _ FP,1'NACE R ■■ GENERATOR INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT I ---j OVEN POOL HEATER ROOM 1 SPACE HEATER ❑ _ ROOF TOP UNIT UNVENTED ROOM HEATER WATER HEATER IIIMI INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES X 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 I'censee does riot have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waive this requirement. ssi -, CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT -1 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 LICENSE# ) 5-2 I✓k SIGNATUR MP MGF❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑4i PARTNERSHIP ❑ii LLC❑ti COMPANY NAME \ leK4 Zv`ADDRESS T J g( y 6 E S 7 CITY 1�'�7\ f STATE f`� ZIP U ZGr� TEL 6 �� -UZb_ Zq9 FAX CELL EMAIL �"L('5 4-4e ZOI 0 e ya✓L4). C.4„1/4-t • o GH GAS IP,ISFE� ION NOTES TillS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • • FEE: $ PERMIT# PLAN REVIEW NOTES