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Home My WebLink AboutBLDG-20-001570 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE September 20,201 PERMIT# BLDG-20-001570 JOBSITE ADDRESS 52 PAYSON PATH OWNER'S NAME COSTA LAWRENCE A G OWNER ADDRESS COSTA LINDA L PACCIA 475 TREMONT ST TAUNTON MA 02780 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ /(( RESIDENTIAL 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 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE 1 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 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 Stephen Roberts LICENSE# 5104 SIGNATURE MP 0 MGF ❑ JP 0 JGF❑ LPG' ❑ CORPORATION D# PARTNERSHIP ❑# LLC ❑#�� COMPANY NAME: STEPHEN W ROBERTS ADDRESS. 17 LAKE DR, CITY PLYMOUTH STATE MA ZIP 023605647 TEL FAX CELL EMAIL y7C�' ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El FEE:$ PERMIT# PLAN REVIEW NOTES LM -7(g _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMFT TO PERFORM GAS FITTING WORK I % 0x cri-t 195?-?%20/ # aO o " 1 � ,,.—s, CITY Ir�r. DATE P_RMIT.� �d�S 0 JOBSITE ADDRESS S.a P4 i Sam / OWNERS NAME /112/ "- S� GOWNER ADDRESS TEL 6Y7 999 3(// FAX • TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL M PRINT CLEARLY NEW:'gib RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ i APPLIANCES FLOORS—F BSM 1 2 3 4 5 6 7 9 10 11 12 •13 14 1 BOILER BOOSTER I CONVERSION BURNER I R llI COOK STOVE I I I DIRECT VENT HEATER ill P 8 p �' DRYER FIREPLACE t ING ,EPA ►t i FRYOLATOR FURNACE GENERATOR __ MIN GRILLE _ INFRARED HEATER I LABORATORY COCKS - I MAKEUP AIR UNIT I OVEN I POOL HEATER ROOM I SPACE HEATER 1 ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I ` OTHER I `� I I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES jt 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 ► ebest of my knowledge `; and that all plumbing work and installations performed under the permit issued for this application will be in compliance IIPefttnent-provision o_f the 1 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. LE PLUMBER-GASFITTER NAME, 7T Ptr,,Ii p.6t 2 IT LICENSE#5s(O 4- SIGNATURE MP ❑ MC-IF❑ JP❑ JGF 5 LPGI ❑ CORPORATION❑#i j PARTNERSHIP❑# LLC❑ COMPANY/� NAME ADDRESS l Z.�e I) r /�CITY —j"/-14 Oa r STATE,/1/4//` ZIP e9e?36 TEL FAX CELL EMAIL l/l/[ Q STr ta /20rf&i5 qD► i'St f6 ROUGH GAS INSPECTION NOTES THISPAGE FOR INSPECTOR G€ USE ONLY FINAL INSPECTION NOTEg Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ • FEE: $ PERMIT(t PLAN REVIEW NOTES