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HomeMy WebLinkAboutBLDG-21-005232 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kl i CITY YARMOUTH MA DATE March 15,2021 PERMIT# * BLDG 21-005232 r-ti JOBSITE ADDRESS 4 ROSE ARBOR RD OWNER'S NAME WATSON ROBERT W G OWNER ADDRESS 4 ROSE ARBOR ROAD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES El 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 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER . LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 11 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 Andrew Leighton LICENSE# 16130 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPG' 0 CORPORATION 0# PARTNERSHIP ❑# Lc 0# COMPANY NAME: ANDREW R LEIGHTON ADDRESS. 20 Brewster Rd, CITY W Yarmouth STATE MA ZIP 026735706 TEL FAX CELL EMAIL halloilcompanya@gmail.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 _ IVIASSA HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'vim- e '' CITY CI t 0-[C,C. -ti �- - MA DATE f-310 / PERMIT# 13LDL -1 -cc 5 Z 3 L - f 1 JOBSITE ADDF :SS 'y /70.� iP,q Cc Rc OWNER'S NAME v /c x- (Lee.Ku,- (4 GOWNER ADDR SS ( ' ' J TYPE OR . . TEL fa:‹.-�/ j (o FAX PRINT OCCUPANCY 1 'PE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: F :NOVATION: REPLACEMENT: • PLANS SUBMITTED: YES NO 17 APPLIANCES 1 FLOORS BSM 1 2 3 4 5 8 7 8 9 10 11 1 12 j 13 14 BOILER l { BOOSTER i � • CONVERSION BURNER - I -� COOK S-OVE _ DIRECT VENT HEATER I DRYER FIREPLACE l FURNACE'OR ( . . -I _ f 1 - - GENERATOR ! _I -I I ► f 1 GRILLE I I I I I INFRARED HEATER • i LABORATORY COCKS - i .. MAKEUP AIR UNIT I - i - I, ' I i . . f OVEN l - - , I 1 POOL HEATER ROOM 1 SPACE HEATER I I I ROOF TOP UNIT I { I I TEST ' UNIT HEATER ('``' "- - - --_ UNVENTED ROOM HEATER I I _ I i . WATER HEATER " OTHER i I i f I i _ ] ! I I i I I I I I I I 1 I I INSURANCE COVERAGE I have a current liability insuranc policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES .I/NO I IF YOU CHECKED YES,PLEASE IN CA s E THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY tISURANCE POLICY V OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,an that my signature on this permit application waives this requirement. ++I CHECK ONE 0 Y: OWNER AGENT SIGNATURE OF C VNER OR AGENT I hereby certify that all of the details; xd infortnacn I have submitted or entered and that atl plumbing work and instal tionaregarding this aPp ill intion era ie and -- ': -b-- or my knowledgehe periter tie under me pea Laws. Issued for this application will be .. plian ,w .,,,,-..ion of the Massachusetts State Plumbing GodE and Chapter 142 of the General Laws. / i" 11101.'- PLUMBER-GASFITt ER NAME At IREW 1.�lGH i ON / LICENSE?± 161 s0-M VW-f SIGNATURE MP ' MGF JP AP LPGI CORPORATION f Y 3734C m COMPANY NAME: HALL OIL COME zNY INC. ADDRESS 4-35 RT 134 CITY SOOT-i DENNIS STATE MA ZIP 02680 PARTNERSHIP i FAX 508-394-n68 CELL TEL 508-338-383 i LC # EMAIL haiiok.ompany@gmail,com 1 I