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HomeMy WebLinkAboutBLDG-17-005902 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE May 12, 2017 PERMIT# BLDG-17-005902 1 JOBSITE ADDRESS 37 COGSWELL PATH OWNER'S NAME CARTER NANCY M G OWNER ADDRESS 28 MIDLAND DR VERNON CT 06066 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111 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/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 LI 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 Kevin Saunders LICENSE# 3860 SIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Kevin C Saunders ADDRESS 67 HELMSMAN DR, CITY YARMOUTH PORT STATE MA ZIP 026752467 TEL FAX CELL I I EMAIL _, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK :F �'�(�`- 7 • CITY U� 1 el �" MA DATE -� 'IQ —17 PERMIT# JOBSITE ADDRESS 37 �,.. A T ` O1 4ER'S NP E061 -`te.(`S) GOWNER ADDRESS 7 /6 TEL*.ixi.5'77q FAX 'TYPE O$ OCCUPANCY TYPE COMMERCIAL[T EDUCATIONAL ❑ RESIDENTLAL PRINT CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT:[3/ PLANS SUBMITTED: YES❑ NO 0 APPLIANCES 1 FLOORS-. SSIM 1 2 3 4 5 I 5 7 S ii 12 13 14 BOILER 1 BOOSTER I CONVERSION BURNER COOK STOVE DIRECT VENT HEATER [DRYER FIREPLACE FRYOLATOR } FURNACE GENERATOR i • f i GRILLE I 1 l INFRARED HEATER LABORATORY COCKS . MAKEUP AIR UNIT OVEN POOL HEATER ROOM. SPACE HEATER ROOF TOP UNIT Ii UNIT HEATER UNVENTED ROOM HEATER WATER HEATER r OTHER t INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES 7 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1_,x. OTHER TYPE INDEMNITY (_, BOND L OWNER'S IN SURANCE 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 rereby certify that 31 31 the details and IMarmatton I nave submided or entered regarding this application are true and accurate ^ e. -a of , owiedg e and trim 31 pluming wart and instanattors performed under tme permit Issued for this application will tie In compliance Myrt^ a er pro . .of tie Mae.3cnusett5 Slate Plumbing Code and Cl ter 142 of tine General Laws PLUMBER-GASFITTER WI Kevin Saunders L CEN SE =4546M, 3860J ' MP❑ MGF❑( JP C JGF X _FGI ;_._) CORPORATION[= PARTNERSHIP = LLC❑* COMPANY NAME Seaside Gas Service, Inc A`ORE_E 67 Helmsman Dr CRY Yarmouth Port STATE MAl' 02675 -`L 508 771 2768 FAX _L 508 400 0943 :r.,; _ PERMITS©seasidegasservice.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ _ PERMIT# PLAN REVIEW NOTES