HomeMy WebLinkAboutBLDG-23-002899 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
e' -'6 CITY YARMOUTH MA DATE November 28,202;PERMIT# BLDG-23-002899
JOBSITE ADDRESS 26 MEDINAH DR OWNER'S NAME REIMER JAMES T
G OWNER ADDRESS REIMER DIANE M 26 MEDINAH DR YARMOUTH PORT MA 02675-1634 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES El NO El
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 1
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:Replace gas line to furnace
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO❑
IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY El BOND 0
OWNERS 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 Craig Bishop LICENSE# 15101 SIGNATURE
MP El MGF El JP 0 JGF El LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME: High Efficiency LLC ADDRESS. 378 Route 130,
CITY Sandwich STATE MA ZIP 025632342 TEL 5088253695
FAX CELL EMAIL
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