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HomeMy WebLinkAboutBLDG-22-003774 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ILe a CITY YARMOUTH MA DATE January 06,2022 PERMIT# BLDG 22-003774 JOBSITE ADDRESS 55 REID AVE OWNER'S NAME KOUNADIS DENNIS G OWNER ADDRESS 76 WEBSTER RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES ❑ 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❑ 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 Dennis Gagne LICENSE# 9804 SIGNATURE MP© MGF ❑ JP 0 JGF 0 LPG! ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: DENNIS M GAGNE ADDRESS. 31 Cherrywood Ln, CITY Marstons Mills STATE MA ZIP 026481761 TEL FAX CELL EMAIL gagneamg51[7naol.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 "� ----�� q.SACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS RI-TING WORK R CITY MA DATE PERMIT#b 2 I2 1B TE DDRESS 3 J` '/D of t!/•/�k/f'/ri,. / OWNER'S NAM7/�n/ v B ILDIG EPA kgvvriltR. DURESS TEL FAY, B TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Et-- PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ®"'"-- PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS--I BSIv1 1 2 3 1 5 6 7 B 9 10 111 12 13 14 BOILER BOOSTER CONVERSION BURNER, _ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE t GENERATOR GRILLE 1 INFRARED HEATER I LABORATORY COCKS MAKEUP AIR UNIT OVEN 'l POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER _ UNVENTED ROOM HEATER WATER HEATER OTHER _ � I I I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ND ❑ 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 al/Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# SIGNAT MP 1GF❑ JP ❑ JGF❑ LPGI❑ CORPORATION❑ F PARTNERSHIP❑# LLC❑# COMPANY NAME if�/J /-"7 ADDRESS 5/ C%r ese;P2It.GG/J a4--e CITY dam+S /mil/ STATE /274 ZIP D267, TEL FAX CELL? 636'&7/ Y EMAIL C 61z'J- ✓7 6-cJe0 e o • CG�✓t I 1 G/ Z. I 0 P I I I I 4 1 4 I I 1 1 1 1 j z 1 o Im, I � V 1 Cr..) I 1_ w1 2 w i C) u�.t 4 F- Gr1 .. f C eL . . a a L CA CO 4 G) < rli C.> 7.1 C- CL EL CO Iii I r IL 1 Cip ti Z. 0 I Fa I C) 1 w 1 4.4 1 I co 0.,,4 1 Cori 0 0