HomeMy WebLinkAboutBLDG-17-003206 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
miza- 1= CITY SOUTHYARMOUTH � MA DATE 12/5/16 PERMIT# ��T'�7'(�7✓�o�OG
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JOBSITE ADDRESS! 1 DANCING BROOK ROAD I OWNER'S NAME„
G A'BRUNZO I
OWNER ADDRESS 1 DANCING BROOK ROAD 1 TEL 774-4870617 (FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIAL _,
PRINT
CLEARLY NEW: ,_, RENOVATION: REPLACEMENT PLANS SUBMITTED: YES: NOD
APPLIANCES 1 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 i
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS 1 UV
MAKEUP AIR UNIT 7 L '-1
OVEN
POOL HEATER
ROOM/SPACE HEATER � ,
ROOF TOP UNI --11—
TEST _.
UNIT HEATER
UNVENTED ROOM HEATER ,,,
WATER 11FATFR J1
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES i NO
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 b ' compliance with Pei' nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
/L'.
PLUMBER-GASFITTER NAME ADAM TRAYNER ,LICENSE III 3880 IGNAT0'E
MP, I MGF'� JP U JGF L LPGI® CORPORATION EI# 173 PARTNERSHIP # I LLC❑#
COMPANY NAME: ROBIES HEATING&COOLING a ADDRESS 279 YARMOUTH RD
CITY I HYANNIS I STATE` MA ZIP102601 TEL 508-775-3083
FAX 508-534-1272 1 CELLI 774-836-5659 EMAILI MARY ROBIES.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