HomeMy WebLinkAboutBLDG-21-007427 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
L4 ,11 CITY YARMOUTH
MA DATE June 21,2021 PERMIT# BLDG-21-007427
JOBSITE ADDRESS 33 CENTERBOARD LN OWNER'S NAME WENBERG CARL 0 TR
G OWNER ADDRESS THE 22 CENTERBOARD LN RLTY TR 33 CENTERBOARD LN SOUTH YARMOUTH MA TEL
02664
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
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
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 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 ❑ 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 Kevin Saunders LICENSE# 308 SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPG' LI CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: SEASIDE GAS SERVICE INC ADDRESS. 67 Helmsman Dr,
CITY Yarmouth Port STATE MA ZIP 02675 TEL 5087712768
FAX CELL 5084000943 EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT El El
FEE:$ PERMIT#
PLAN REVIEW NOTES