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HomeMy WebLinkAboutBLDG-23-000159 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE July 11,2022 PERMIT# BLDG-23-000159 Ii JOBSITE ADDRESS 43 PHYLLIS DR OWNER'S NAME REED ROBERT G OWNER ADDRESS REED MARY M KELLY 43 PHYLLIS DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL 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 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 LABILITY 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 Gregory Selfe LICENSE# 26714 SIGNATURE MP❑MGF❑JP© JGF❑ LPG! ❑ CORPORATION❑#I I PARTNERSHIP ❑# LLC❑# COMPANY NAME: GREGORY A SELFE ADDRESS. 41 SPRINGER LN,41 SPRINGER LN CITY WEST YARMOUTH STATE [MA ZIP 026734930 TEL FAX CELL EMAIL setecreanc.yahoo.com S310N M3IAal NV'ld # $ :33d ❑ ❑ 1IIN213d 3H1 Sd S3A2:13S N011VOflddd SIHI oN seA S31ON N01103dSNI 1VNH A1N0 3sn d0133dSNI 21O 13DVd SIHI S310N NOI103dSNI SVO HOf1021 ' ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1�IP`t`'L �` CITY Y f�(Z{Y)0� Ir4P, DATE --)-it`aa E �+ 23 0/1 ��'� PERMIT JOBSITE ADDRESS 413 Ph y - .is- DR\ye OWNER'S NAME /1 e fi GOWNER ADDRESS 4 3 Ph yL-t-I S DR I v e TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL lk CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ® PLANS.SUBMITTED:„UBMITTED YES r ❑ NO APPLIANCES FLOORS—I li:lui 1 ? 3 4 5 6 7 q BOILER 9 10 II t? 13 14 l BOOSTER CONVERSION BURNER I COOK STOVE DIRECT VENT HEATER DRYER �j FIREPLACE i FRYOLATOR + FURNACE GENERATOR • GRILLE INFRARED HEATER - LABORATORY COCKS __________I MAKEUP AIR UNIT • OVEN ; POOL HEATER • ROOM/SPACE HEATER i c E I 'I E i ROOF TOP UNIT __... .. .. __ TEST .-. . • ... _. ._. .._... .j UNIT HEATER �' LINVENTED ROOM HEATER WATER HFATEFZ BUI i DING DErARTME OTHER I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES ® ND 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY 0 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT EIJT 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#a•67rY SIGN URE MP ❑ MGF❑ JP © JGF ❑ LPGI ❑ CORPORATION ❑t PARTNERSHIP❑it LLC❑# COMPANY NAME646oer TO lie PI!4778106 SeYtce ADDRESS 41( 5P1=In 6 E 12LR 0c CITY 6t/• 6h2m. STATE al ZIP Od673 TEL( C) .7g- /Y Y FAX CEL(.5%45)1.1$-I(11 Y EMAIL e)Ce fe C Ahoo. Cow ROUGH g�ti I ECTI�l� I�1Q` ' ,� THIS PAGE FOP, INSPECTOR USE OrsiLX FINAL INSPECTION NOTES Its 'fey No THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT it PLAN REVIEW NOTES