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HomeMy WebLinkAboutBLDG-21-007467 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ;kr, CITY YARMOUTH MA DATE June 22,2021 PERMIT# BLDG-21-007467 -,, JOBSITE ADDRESS 110 SOUTH SEA AVE OWNER'S NAME HARRIES ANN LOUISE TRS G OWNER ADDRESS ANN-LOUISE HARRIES TRUST 110 SOUTH SEA AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III 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 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 LICENSE# 34056 SIGNATURE MP 0 MGF 0 JP© JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: THEO PLUMBING AND HEATING LLC ADDRESS. P.O.Box 397,P.O.Box 397 CITY Centerville STATE MA ZIP 02632 TEL FAX CELL EMAIL theoplumbinq(a)yahoo.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 1 t: ,6 CITY eS V1 A..-6 .A2.--. MA DATE Go -2 ?G Z \ PERMIT # QL T- 1-U01 L1 (o7 JOBSITE ADDRESS \ Io 5 - 5PC 0 -12 OWNER'S NAME fAvIn c' --(--0`' 'Y (tbbter e. GOWNER ADDRESS TEL 1 -7 6 20 OFAX TPRINYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL �-� CLEARLY NEW: _ RENOVATION: ❑ REPLACEMENT: 0/ PLANS SUBMITTED: YES ❑ NO n APPLIANCES 1 FLOORS BSIv1 1 2 3 4 5 6 7 8 9 10 'I1 12 13 1 BOILER I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYEP. i i FIREPLACE I FRYC)LATOR I FURNACE" GENERATOR GRILLE i INFRARED HEATER —� I LABORATORY COCKS MAKEUP AIR UNIT ! `;:' 97: ,. -y 1 '., I OVEN I POOL HEATER I g , ROOM / SPACE HEATER r .```' ; I t ' t 1 ROOF TOP UNIT UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I _ I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL. Ch. 142 YES O ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE yE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND I 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 ❑ 1 SIGNATURE OF OWNER OR AGENT 1 L I hereby certify that atl 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 wi 'nent provision of the,Lo Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME N ,c IhtG .e, d•S LICENSE # _ -3,,,, SIGNATURE pi_ ,- 5 � 'y SIGNATURE / MP ❑ MGF ❑ JP tZ4GF ❑ LPGI ❑ CORPORATION ❑ IF PARTNERSHIP SHIP El it 1 LLC gl: c)c}t 1�'caci 3 2_ f@ COMPANY NAME \ (-)kr^ (9`'1— (4e 4 r,, -h5 ADDRESS e>.6 6 ci .-el-) CITY C el"le/ v. 1 e STATE w\(>' ZIP G CaV 56q. FAX CELL EMAIL -,-- i sec.piv ,--..--- h, , " e ,,,, (...,„, . , c--,--, c,63.# -,. 5v ROUGH GAS INsFEci'IGN NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES (es No • THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT ft PLAN REVIEW NOTES