HomeMy WebLinkAboutBLDG-20-001528 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�r ( CITY YARMOUTH MA DATE September 18,201 PERMIT# BLDG-20-001528
JOBSITE ADDRESS 1 OLD CASTLE RD OWNER'S NAME WILSON SHAUN S
G OWNER ADDRESS WILSON CHRISTINE B 1 OLD CASTLE RD YARMOUTH PORT MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ID
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑
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 I 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 ❑
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 Leon Clark LICENSE# 11734 SIGNATURE
MP 0 MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑ # PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: LEON E CLARK ADDRESS. 16 PLASHES DR,
CITY DENNIS PORT STATE MA ZIP 026391505 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 ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES