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Home My WebLink AboutBLDG-22-000940 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK TGl `' CITY [YARMOUTH J MA DATE August 18,2021 PERMIT# BLDG-22-000940 17 Nts> JOBSITE ADDRESS 441 ROUTE 6A —I OWNER'S NAME SUMMERFIELD MARTIN A G OWNER ADDRESS SUMMERFIELD MARGO T 441 MAIN ST YARMOUTH PORT MA 02675-1824 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 1 FRYOLATOR FURNACE 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: 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 ❑ 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 Ronald Hague LICENSE# 7636 SIGNATURE MP Q MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: [RONALD J HAGUE ADDRESS. 62 NEW BOSTON RD, CITY DENNIS STATE MA ZIP 026381901 TEL FAX 1 CELL EMAIL ronhaque(aacomcast.net S3 LON M3IA3H NVId #IRAIH3d $:33d ❑ ❑ 111A1H3d 3H1 SV S3A213S NOIlVOIlddV SIHl oN saA S31ON N01103dSNI 1VNId AINO 3Sf1 a0103dSNI 2:10d 3OVd SIHI S31ON NO1103dSNI SV0 HOflO J MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY \-1 k v^o kA tixp Jd 4- MA DATE 1 1 PERMIT# Z Z - 2116 L ) JOBSITE ADDRESS 'AY V \ o 4 '( OWNER'S NAMEM0r t`n ap i OWNER ADDRESS TEL FAX PG OF OCCUPANCY TYPE COMMERCIAL EDUCATIONAL f = ItINT ❑ ❑ RESIDENTIAL LI Q I EALRLY NEW:❑ RENOVATION: i REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO�] X � APPI 4NCES 1 FLOORS-4 BEN 1 2 3 1 5 6 7 8 9 10 1'1 12 13 14 BOILER ---� BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER 1 I DRYER, FIREPLACE Ir FRYOLATOR FURNACE GENERATOR '�— GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST . . . . . ._ • - .. UNIT HEATER INVENTED ROOM HEATER ' WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ 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 7,1: 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 comp ance wit all 'ne provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFIT-IER NAME LICENSE# 763 6 SIGNATURE MP ❑ MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑it PARTNERSHIPr ' ❑# LLC❑# ] COMPANY NAME 61C 1A-.( \k. ADDRESS � "-e'u is (VO r 2 d' CITY b Q"A' STATE04"4 ZIP b 3 4- T SVk) J 30 ti %(-U FAX CELL EMAIL 4'un ("y V? e Co'M Cce) -I-- e 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