HomeMy WebLinkAboutBLDG-16-004229 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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tF.I16 CITY WEST YARMOUTH MA DATE 1/19/16 PERMIT# /3A-Vb / -r--0 -/
JOBSITE ADDRESS' 30 WHALE RD I OWNER'S NAME 1 FORG
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OWNER ADDRESS 30 WHALE RD TEL 617-733-5077 1 FAX1
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL rij
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES D NO
APPLIANCES 1 FLOORS--. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILERk_ Imo _ ., ; �_ ..
BOOSTER , ; a
CONVERSION BURNER ,v_
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOP. 1
FURNACE
GENERATOR
GRILLE
INFRARED HEATER ,'
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN, . ..
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT TEST I...UNIT HEATER ; ; _
UNVENTED ROOM HEATER - f
WATER HEATER
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OTHER 1 1
1:
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO s
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 171 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 a__ AGENTS
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 st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will b . ompliance with al ertin t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME ADAM TRAYNER LICENSE# 3880 N URE
MP A MGF• JP Li JGF A LPGI , CORPORATION; # 173 PARTNERSHIPD# LLC # I
COMPANY NAME: ROBIES HEATING&COOLING ADDRESS 279 YARMOUTH RD
CITY HYANNIS I STATE F—M-Al ZIP 02601 TEL 508-775-3083
FAX 508-534-1272 CELL 774-836-5659 EMAIL
M/I-
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPEECTION NOTES
Yes No M/4 it'd PRO fi 00)
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES