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Home My WebLink AboutBLDG-21-007442 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 22,2021 PERMIT# BLDG-21-007442 L., t'$,� ' JOBSITE ADDRESS 18 MACKENZIE RD OWNER'S NAME VILLA JAMES A SR TR G OWNER ADDRESS 18 MACKENZIE RD REALTY TRUST 16 BIRCHWOOD DR PRINCETON MA 01541 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER , COOK STOVE DIRECT VENT HEATER . DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT , OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT . TEST . UNIT HEATER UNVENTED ROOM HEATER - , WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY El BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Kristopher Olson LICENSE# 31454 SIGNATURE MP 0 MGF 0 JP❑ JGF 0 LPG' 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: KRISTOPHER E OLSON ADDRESS. 33 James St,Apt 2 CITY Worcester STATE MA ZIP 016031013 TEL FAX CELL EMAIL kriseolson1983Ahotmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK = � CITY 7)„,, t Yc ' &ftlf. MA DATE L I PERMIT # 1_ DC 7 f Li Lag JOBSITE ADDRESS /E . Ind OWNER'S NAME . ,,-, 1, . ic., GOWNER ADDRESS - M n t. ' y TEL &�"e3S' "3tefi FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL Q' PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ( jv PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES -1 FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 8/ 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 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 Fr NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY R 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 ❑ 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 I'&r trLer LICENSE # i SIGNATURE 3 'N5� MP ❑ MGF (—I JP P JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP [l # Lc ❑ # COMPANY NAME eccr, "It, ADDRESS '3(1)2- A4ci4.'1 �J-51- pJ- CITY ,_ " �.t� (� � �--', •L& , STATE/ , ZIP OIS 1S v TEL � ?�t S�� I FAX CELL EMAIL k<t)-scdfc:/) 1