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HomeMy WebLinkAboutBLDG-23-005064 .T MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .... ig, =_ .„ .' CITY YARMOUTH MA DATE March 15,2023 PERMIT# BLDG-23-005064 JOBSITE ADDRESS 500 ROUTE 6A OWNER'S NAME FITZGERALD SHEILA M TRS G OWNER ADDRESS SMF REALTY TRUST PO BOX 535 YARMOUTH PORT 02675-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 111 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER , BOOSTER CONVERSION BURNER , COOK STOVE 2 , DIRECT VENT HEATER DRYER - , FIREPLACE 1 FRYOLATOR , FURNACE 2 , GENERATOR GRILLE INFRARED HEATER , LABORATORY COCKS , MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER , WATER HEATER 2 , 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 0 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 State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Eugenijus Jagminas LICENSE# 3590 SIGNATURE MP❑ MGF © JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Eugenijus Jaqminas ADDRESS. 34 ELIJAH CHILDS LN, CITY CENTERVILLE STATE MA ZIP 026322112 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ El FEE:$ PERMIT# PLAN REVIEW NOTES Ira _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,r =-i°� � CITY CL,22 MA DATE � � ERMIT# J Z�'C�SOG I JOBSITE AD,CSRESS lj �Ci g � 0 ER'S NAME - //: &id/ `'i G � / OWNER ADDRESS I � I TEL I / I FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL L�' PRINT .,/ PLANS SUBMITTED: YES❑ NO[ CLEARLY NEW: ❑ RENOVATION: L�,3 REPLACEMENT:❑ FIXTURES Z FLOOR--. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 1 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER . DRYER FIREPLACE ti / FRYOLATOR . FURNACE ' ' GENERATOR GRILLE LABORATORY COCKS _ - — _ MAKEUP AIR UNIT _ . OVEN POOL HEATER - ROOM/SPACE HEATER ' ROOF TOP UNIT . TEST UNIT HEATER UNVENTED ROOM HEATER . WATER HEATER ). INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ 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 waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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 bes my knowlei and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe•'•�,i % •ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /APIP � PLUMBER/GASFITTER NAME:I �l Z'`1 `,r9/;/vi9 S. I LICENSE#I i?J-e d I SIGN' ' R COMPANY NAME:I /t' ,i/ ' c/7'iv i! ' I ADDRESS:I ( - /) z,�') ,/ CITY:I 5',,.9), IC 7/, I STATE: /19 4- ZIP: (;)(4< .a FAX: TEL: [ I CELL: EMAIL: MASTER IURNEYMAN 0 LP INSTALLER 0 CORPORATION❑# PARTNERSHIP❑# LLC❑#n