HomeMy WebLinkAboutBLDG-19-002783 1:'',,. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
.;s CITY _e-r- r.�Y -' MA DATE 1I/ 0/' PERMIT#h1-/)e ;,l,-VI
JOBSITE ADDRESS 64' to V i JO. OWNER'S NAME dcr>Z /TE//
GOWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL A/
P "J!
CLEARLY NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS-4 Sis 1 2 3 21 5 5 7 8 9 10 11 12 13 1'
BOILER
BOOSTER t
CONVERSION BURNER
COOK STOVE I
DIRECT VENT HEATER _
DRYER
FIREPLACE I
FRYCiLATOR `
FURNACE _ _
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER I
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 IUIGL.Ch.'142 YES TA- ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Vr--- OTHER TYPE INDEMNITY ❑ BOND ❑ 1
• 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 waive::this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT i
+ I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc ate to the best of my knowledge
`k- and that all plumbing work and installations performed under the permit issued for this application will be in compliance ' all Pertinent provision "
`- Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 6l e i�_ S'( �'•
�w LICENSE#ZC,gi SIGNATURE
MP ❑ MGF❑ JP GF❑ LPGI ❑ CORPORATION❑#F PARTNERSHIP E#� LLC❑## 1
COMPANY NAME ADDRESS 20 DZc„c.o1....s R J /0--(4.-
CITY (TLrr..r,`c..-L STATE CM ZIP 0 ..,d 45, TEL 22*'' - ,-` 0Y7C 1
FAX CELL EMAIL /
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PERMIT
DIG SAFE NUMBER
City or Town: Yarmouth
Date: 11/06/2018
Start Date:
Permit Number(if applicable) 102363
In accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A this permit is granted
to: New England Plumbing
For permission to: Unvented Gas Heater Installation 527CMR 1.12.8.6
Restrictions: Strict and complete compliance with all federal, state and local laws, rules, regulations and codes.
Notify YFD before and after work is complete.
At: 806 WEST YARMOUTH ROAD /South Yarmouth, MA 02664
Fee Paid $ $50.00 This permit will expire on
Signature of Official Granting Permit 7-- Title C. A ? I - C ` U C /
This permit must be conspicuously posted upon the premises