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HomeMy WebLinkAboutBLDG-23-004786 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK TM lc CITY YARMOUTH MA DATE February 28,2023 PERMIT# BLDG-23-004785 �xW JOBSITE ADDRESS 18 AUTUMN DR OWNER'S NAME Diego Baveloni G OWNER ADDRESS 18 AUTUMN DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 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 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 1 OTHER DESCRIPTION:cap off line 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 BOND ❑ OWNERS 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 BRADLEY TOMASETTI LICENSE# 16544 SIGNATURE MP©MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# I PARTNERSHIP ❑# LLC❑# COMPANY NAME TOMASETTI PLUMBING ADDRESS. 103 UNION ST, CITY YARMOUTH PORT STATE MA ZIP 02675 TEL FAX CELL EMAIL tomasettiplumbingtEgmail.com 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 e,..```'" '` 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK RK 1 CCC.Y_� t / _ 14, �� , c_ Imo, DATE Z`Z T/Z o Z3 PERMIT 2"3 ._ `, p- L Y�rl CB 27 TE D ESS �O ittiTL.44 , )— ! OL NER'S NAME ±f r n ,i_f a2 OWNER DRESS iii)-ikbii L) ARTMENT TEL I PF� FAX - ••- -- . " TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW: ❑ RENOVATION: Ei., REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO APPLIANCES-1 FLOORS BEM 1 2 3 4 5 6 ? g BOILER 9 10 11 12 13 1" BOOSTER CONVERSION BURNER COOK STOVE / DIRECT VENT HEATER DRYER FIREPLACE i FRYOLATOR _� FURNACE �-- GENERATOR GRILLE • INFRARED HEATER _ LABORATORY COCKS MAKEUP AIR UNIT • OVEN POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT TEST _.. UNIT HEATER • INVENTED ROOM HEATER WATER HEATER OTHER Fi CUPcG S 1.rt ( INSURANCE COVERAGE r I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES O I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW [3 LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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. 3 SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT El `'.-• 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 L' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBS -GASFITTER NAME J 77 _// lit /�� /6��5 el -� LICENSE# /td 5 y� IGNATURE MP MGFC� ❑ JP ❑ JGF❑ LPG! 0 CORPORATION❑#i PARTNERSHIP 0�r LLC # COMPANY NAME w.e. t - f ADDRESS 1Z2/3 (./h.�`. �T CITY G��-. &f STATE/4-74 ZIP 6 0 75— TEL FAX CELL -- BIZ ? -L�0 ( EMAIL rr.c ..el -- i ter, I 1 I G., H 0 1 H 1 (..� 1 r C{) 1 I 1 I I I 1 zE Z G or) a 1 rf1 1.- Vl cad I 0., H 0 W 0 0 1 w = F- ja., 1-- n• w 1 r — rr w. 1 cn W 1 O ui 14 La U D" - O w 1= 5 --i H a_ a_ us tU i— Ill u_ 1 1 0 Y H Cam-, 0 1 L) l 1 1 co") +1,--y r7 I 0 {�a t 1 1 , :1