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HomeMy WebLinkAboutBLDG-21-006727 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _r LiBLDG-21-006727 - _=ire CITY YARMOUTH FI `{> r:.ti> MA DATE May 20,2021 PERMIT# JOBSITE ADDRESS 6 MORGAN RD OWNER'S NAME O'DONNELL C MICHAEL G OWNER ADDRESS 6 MAPLE ST BEDFORD MA 01730 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ 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 . BOOSTER . CONVERSION BURNER COOK STOVE , 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 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 Robert Judson LICENSE# 16399 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: ROBERT J JUDSON ADDRESS. 34 SCHOOL ST, CITY MERRIMAC STATE MA ZIP 018601938 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE:$ PERMIT# PLAN REVIEW NOTES a IP MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . . tl CITY YARMOUTH i, MA DATE 05/12,20211 PERMIT # C3 JOBSITE ADDRESS 6 MORGAN ROAD _ OWNER'S NAME MICHAEL O'DONNELL 1 GOWNER ADDRESS 6 MORGAN ROAD j TEL 6176996406 JFAX . TPR OR OCCUPANCY TYPE COMMERCIAL r' EDUCATIONAL RESIDENTIAL F.' CLEARLY NEW: RENOVATION: J REPLACEMENT: iz PLANS SUBMITTED: YES rj NOLI APPLIANCES Z FLOORS--• BSM 1 1111 3 4 III 6 7 1 8 9 10 11 12 13 14 BOILER BOOSTER - Y _.__ CONVERSION BURNER COOK STOVE 'WINO IMMO11111111111111111 DIRECT VENT HEATER 1== ____, r____ _____ DRYER L _ _ FIREPLACE �. �.... FRYOLATOR E _. 1 FURNACE 1 _ `MI ,,ii L GENERATOR GRILLE INFRARED HEATER L 7117 .- WM -±LABORATORY COCKS _ �_ MAKEUP AIR UNIT l „a '"i 1 . OVEN ......... POOL HEATER ROOM 1 SPACE HEATER _�1 - Aim- ROOF TOP UNIT E„.± —1f— � TEST L r- _ UNIT HEATER L ______11111 MIMI . _ _____, UNVENTED ROOM HEATER WATER HEATER OTHER T -74 M :-- -- L- --z INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES v NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY , 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. _�� /1 '. PLUMBER-GASFITTER NAME IROBERT JUDSON LICENSE # 16399 , 1117"U. 7 MP Ti MGF D JP JGF LPG! LI CORPORATION E,# 14115 PARTNERSHIP 1#1 ____ LLC 1# , COMPANY NAME: DIPIETRO HEATING & COOLING ADDRESS E.2.LV1IDDLESEX ST CITY !HAVERHILL STATE MA ZIP[01835 TEL 9783724111 FAX 1 CELL EMAIL[DEANNAS@CALLREVISE.COM