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HomeMy WebLinkAboutBLDG-22-001213 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK wiyil k CITY YARMOUTH MA DATE September 02,202 PERMIT# BLDG-22-001213 JOBSITE ADDRESS 48 PHYLLIS DR OWNER'S NAME PORTER JAMES M G OWNER ADDRESS PORTER TOULA P 48 PHYLLIS DR SOUTH YARMOUTH MA 02664-1680 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL III 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 . FRYOLATOR . FURNACE 1 , GENERATOR . GRILLE . INFRARED HEATER LABORATORY COCKS , MAKEUP AIR UNIT OVEN . POOL HEATER . ROOM/SPACE HEATER , ROOF TOP UNIT . TEST 1 , 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 0 OTHER OF 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. 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 Robert Lalime LICENSE# 13701 SIGNATURE MP© MGF ❑ JP 0 JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: ROBERT C LALIME ADDRESS. 575 Main St, CITY Mashpee STATE MA ZIP 026492054 TEL FAX CELL EMAIL none . S310N M3IA321 NVld #1101213d $:33d ❑ ❑ 1I11213d 3H1 SV S3A113S NOIiVOIlddV SIHI oN S9A S31ON NO1103dSNI lVNId KINO 3Sl 210103dSNI 2J03 30Vd SIN. S310N NOI133dSNI SV0 HJl0N MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I1=l 2 -- ,I . CITY 1 #1 vi el el//J MA DATE / it/ill �/ PERMIT# Z Z- l 2„t 3 4; / / JOBSITE DRESS ,V.e ,z ,,/ OWNERS NAME GOWNER ADDRESS TEL FAX • TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�� PRINT CLEARLY NEW:D RENOVATION: d REPLACEMENT: ❑ PLANS SUBMITTED: YES NO❑ APPLIANCES.1 FLOORS-+ BSM 1 2 3 4 5 6 7 s 9 10 11 12 1 BOILER — BOOSTER CONVERSION BURNER COOK STOVE / DIRECT VENT HEATER j—j DRYER FIREPLACE FRYOLATOR FURNACE ' / GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS � MAKEUP AIR UNIT OVEN [_i POOL HEATER • ROOM/SPACE HEATER IRE C E t V E D ROOF TOP UNIT ._ _.,._ TEST . . ...._ .._... .. . ...... _... UNIT HEATER SEP D I J2.1 , UNVENTED ROOM HEATER WATER HEATER BUILDING �crAi?rnA_OTHER / BY — -___—_ INSURANCE COVERAGE ,_._,� I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES lld n0 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY PZ.- OTHER TYPE 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT T.I, I hereby certify that all of the details and information I have submitted or entered regarding this application are true rate th est of my knowledge `� and that all plumbing work and installations performed under the permit issued for this application will be in corn nce h a ' nt provision of the `` Massachusetts State Plumbing Code and Chapter 142 of the Ge eral Laws. Lo PLUMBER GASFITTER NAME ��/�1 �1�4 LICENSE#/f7// SIGNATURE MP VIAGF❑ JP❑ JGF❑ LPGI ❑ / CORPORATION❑# PARTNERSHIP❑# /LLC❑#' COMPANY NAME (/ /447.h. 7 ADDRESS ,f 7J /�/�/#J / CITY A-J ( STATE/49 ZIP fJ�‘%/ TEL ( rdeP o 21 Q'L/ FAX, CELL EMAIL i/ 9/>7Q.? e r ' - / /' CV 170 7D 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 • ,00 1 q! i