HomeMy WebLinkAboutBLDG-23-003792 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
a�- BLDG-23-003792 CITY YARMOUTH MA DATE January 12,2023 PERMIT#
JOBSITE ADDRESS 15 MALLARD ST OWNER'S NAME David Eaton
G OWNER ADDRESS TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0
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
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
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 0
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
I hereby certify that all of the cetails 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 Barry Smith LICENSE# 33760 SIGNATURE
MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑ # PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: BAP.RY C SMITH ADDRESS. 28 Oval Road Apt 5,
CITY Quincy STATE MA ZIP 02170 TEL
FAX CELL EMAIL BARRYSMI"'HIS(a,LIVE.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
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
� '17. CITY \�\\ MAiPERMIT#
`.�;I,L.;�, IVS" �'.A,1�t� DATE \ � \\ � „3 ,�
JOBSITE ADDRESS \ OWNERS NAME \_X3-�A
OWNER ADDRESS VS \Nr\o. ' TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL 27
Pb'tIfd')!
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES T FLOORS—+ BSM 1 2 3 4 5 6 7 3 9 10 11 12 '13 14
BOILER
BOOSTER j
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE i
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN _
POOL HEATER •
ROOM;SPACE HEATER
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 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 2/ 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 naives 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 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 a,LE rtinent provision of the
- Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� \
PLUMBER-GASFITTER NAME LICENSE#-7- Al-f SIGNATURE
MP ❑ MGF❑ JP ❑ JGF ❑ LPG' ❑ CORPORATION❑# PARTNERSHIP❑41, LLC 2P:
COMPANY NAME C ����•� �� - �� r ADDRESS \-7\1
CITY \C,c�\� � jo STATE V\A ZIP �` � TEL
FAX CELLc --\ ')k.< \2Vgv EMAILAahc�v��� ���s
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