HomeMy WebLinkAboutBLDG-22-004121 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE January 25,2022 PERMIT# BLDG-22-004121
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JOBSITE ADDRESS 21 VINEYARD ST OWNER'S NAME HANLON AMY L
G OWNER ADDRESS OBRIEN JULIE M 33 YOUNGS RD DEDHAM MA 02026 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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
FRYOLATOR
FURNACE
GENERATOR 1
GRILLE
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
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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 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 LESTER WADE LICENSE# 4569 SIGNATURE
MP 0 MGF 0 JP❑ JGF 0 LPG' 0 CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME: LESTER J WADE ADDRESS. 22 CAPTAIN ISIAHS RD,
CITY COTUIT STATE MA ZIP 026352702 TEL
FAX CELL EMAIL
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NIASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING s!ritmay- WORK
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tg fir CITY r`((LC-moo 1 MA DATE t-a u O- a- JPERMIT# 22- IZl
JOBSITE ADDRESS, at Vint y kJ-4- S4 , OWG,iER'S NAME J to( j f 0`6r e_h
_`" OWNER ADDRESS 1 51 CA.. c_(o o\f G TEL l 1-a y q-003 y FAX it •
!_-• .`.. OCCUPANCY TYPE COMMERCIAL 7 EDUCATIONAL I RESIDENTIAL
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G-"'"R V NEW:J RENOVATION:❑ REPLACEMENT.0 PLANS SUBMITTED:ED: YES Li NO
APPLIANCES 1 FLOORS-, I SSM I f ; 2 ; 3 1 •f 1 5 j 6 7 ! 5 ! S J. iQ 1 11 ! 12 t 13 l 14
EO.L.ER - !f -„----- --- -:--' -- _.-.i---_ -._.r--,-._-....., _ ., _.,I
BOOSTERy _ z {, {
ii li fi r i
CCt!trEPS101>!BURNER if r t.--__:1 i I 1 II i,_.___ii r� r
COOK STOVE r—"_� .__....i'=__},._•_ ', ---1�--�------.� . �':Ya--� .- �� -,.—e--. ..
DIRECT'BENT HEATEP, 1—u ` _ .4 _�� —i(-- I_ - !1 ,- •
DRYER Il .-li:�
'-- —i-! �rr
l �
-- � �� __ -= =r i
FIREPLACE y:;. a �,... : ' � p_ st � �
FRYOLATOR ll. . ..it .. __:r 'f
FURNACE- I. 7i , 'r �_ it - J% _l F .t
-_ �.; - _ ` _
GENERATOR
GRILLEam- _,
.r — 1
INFRARED HEATER ____ l_—yi ?-7I �i - ---'i _ '1 - _:. i
LABORATORY COCKS —•�-'—' II ' r !" 1
ivIAKEUP AIR UNIT I' 1a ii ; �-� ;' p
! I, hl I, J N _ _y. I 11--,I is . .. .._ I
OVEN , _17-i : ,I_I 1 y
POOL HEATER If— ,. I •-='-, 7:1 -- ' -•�=, _- ;, -;
•
ROOM/SPACE HEATER ' � '- ': -? `�-�'1 3 r
ROOF TOP UNIT Ii I - -!i rµ __ I_�1! r—II ;f i�` .__. .
UNITTEST . y I
HEATER �_ --, .�I ;j- 1 71 .
UhIVENTED ROOM HEATER �1 _r _— C -� rt_ �'r�(--;� i-
!hfATER HE TER -- _ _ ......3 �.:. _:..=f:i-� ir� -- --=--,s>— �..•-� __-
OTHER `I - _.- •
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_- L_ _ __
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CI II ._. ;I. Lim i • . 1—_:J!_ ,I ;_ —I.N._.._c,..__._ t _
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the re luirements or IvIGL.Ch.14.2 YES '10 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYF F.OF COVERAGE BY CHECKING THE APPROPRIATE BO::BELOW
LIABILITY INSURA\ICE POLICY :2 OTHER TYPE INDEMNITY _j BOND
O NE :'S v'SURANCE WAIVER:t am aware the:the licensee ides not have the insurance coverage required by_C•li Ater 142 of the
Maseschusa)h General Laws,and that my signature on this permit application waives this requh:rnent.
CHECK ONE ONLY: OWNER ri AGENT f_
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
a:is that ud p t robing work andies:allatior�s papter _d under the permit:ssuad for this application Jill be in cot.plianceall?:•ripen;pr the
Massachusetts State PlumbingCone and Chapter 142 of the General Laws am/ (//1f/l
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PLUivIBEP-GASFIrTER NAME l. ce5.�. .r IAJa Ae !LICENSE TI 1+5t0ct J SIGNATURE
MP n MGF(f,/ JP IT JGF LPG 0 CORPORATION�I#r —1 PARTNERSHIP Lag! LLC Dor_ I
CGMFiri'i A/ E:iC&pf, (,fie m erR• n - 4pFIREss 23 (3c,wt.C+4Y► (L(' I
Crr' [t.A4 Lope e_ STATE MA ZIP Oa&tit/ TEL(,50r-col— �' I-$7
FAY L CLLL[ - $D'' ,EMAIL! t Cr'. C.G i P C,e e 1 4'5 . Cc,6vN