HomeMy WebLinkAboutBLDG-17-006101 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY a YARMOUTH PORT MA DATE 5/22/17 =PERMIT# / nlT'17—O0 6/G7
JOBSITE ADDRESS 75 SUMMER STREET OWNER'S NAME TUFTS 1
GOWNER ADDRESS I 75 SUMMER STREET =TEL 508 776 8772 IFAXI 1
TYPE OR OCCUPANCY TYPE COMMERCIALS
PRINT EDUCATIONAL RESIDENTIAL
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
DIRECT VENT HEATER
DRYER w.
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
_GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST 1
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER GAS LINE
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 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 he best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will 'n compliance with a I P inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I ADAM'TRAYNER j LICENSE#!3880 SIGNATURE
MP MGF JP JGF LPG_j CORPORATION 1A#1173 PARTNERSHIP # LLC #
COMPANY NAME:; ROBIES HEATING&COOLING I ADDRESS j 279 YARMOUTH RD
CITY HYANNIS j STATE 7MA—I ZIP;02601 TEL I 508 775 3083
FAX 508-534-1272 CELL1508-775-3083 EMAIL MARY ROBIES.COM
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
0(;>/:/ C THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
Z---1171/-
FEE: $ PERMIT#
C� / / � PLAN REVIEW NOTES