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HomeMy WebLinkAboutBLDG-21-004437 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE February 05,2021 PERMIT# BLDG 21 004437 JOBSITE ADDRESS 9 HOCKANOM RD OWNER'S NAME SANTERRE LINDA M G OWNER ADDRESS 9 HOCKANOM RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El 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 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 ❑ 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 Darrell Shedd LICENSE# 8403 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: DARRELL D SHEDD ADDRESS. 730 TYLER ST, CITY PITTSFIELD STATE MA ZIP 012014319 TEL FAX CELL EMAIL S31ON M31ARN NV1d #JIV d $ 33.d ❑ ❑ 111183d 3H1 SV S3AH3S NOIlV011ddd SIHl oN SeA S31ON NO1103dSNI 1VN13 .LINO 3Sfl el0103dSNI 2103 3OVd SIHl S310N NOIl03dSNI SV€)HDflO 54) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ink14400rei Polo MA DATE _ /2o/z/ PERMIT# s Z1 4T3 1_ JOBSITE ADDRESS 9 Ho6k4Nom RD OWNER'S NAME_KKVT11. 5/1NTvleeE. GOWNER ADDRESS 9 Hock4No m /a) TEL FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL% PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE I 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES IN NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY NI 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 complian with all ine rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C PLUMBER-GASFITTERNAME-1,41QQE1 'S4gDL3 LICENSE# 8yo,3 SIGNATURE MP tz MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑# COMPANY NAME/AWELL 54/EDD P -v.i ,&6 ADDRESS '4 Fa iswas!-f la wA4y CITY NO l?. 7R✓]cd STATE YllA ZIP 6 26SZ TEL 11.E — yYI " 70 9 Cr FAX CELL _ EMAIL dStteAd/��,sheidpI v 4/2; 2 i y.-- --_- ' V`� �B 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 ___