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HomeMy WebLinkAboutBLDG-20-001790 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ''�'—� CITY YARMOUTH MA DATE October 02,2019 PERMIT# BLDG-20-001790 JOBSITE ADDRESS 186 ROUTE 6A j OWNER'S NAME CROOK JAW INN INC G OWNER ADDRESS 186 ROUTE 6A YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL d❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 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 1 _ _ GENERATOR _ 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 OTHER DESCRIPTION: —IV--1 S III INSURANCE COVERAGE: I have a current liability insurance pot cy or i� is 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 El 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. 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 Stale Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Richard Whiteside LICENSE# 15850 SIGNATURE MP 0 MGF 0 JP❑ JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME RICHARD J WHITESIDE ADDRESS. 29 MAPLE TER, CITY SOUTH DENNIS STATE MA ZIP 026603651 TEL FAX CELL EMAIL LP i-J- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No ��S✓ 6,kL Unv A 4 4.6"./20„fA, THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ _le'/V/4 FEE: $ PERMIT# PLAN REVIEW NOTES